Guidelines for the laboratory diagnosis of genital herpes in eastern European countries.

These guidelines aim to provide comprehensive information about sexually transmitted herpes simplex virus (HSV) infection and its laboratory diagnosis in eastern European countries. They are primarily intended for professionals testing specimens from patients at a sexual healthcare clinic but may also be helpful for community-based screening programmes. In particular, the guidelines recommend: (i) either viral culture or validated and approved nucleic acid amplification tests (NAATs) as the tests of choice for symptomatic patients, which should be promoted for laboratory confirmation of HSV infection; (ii) if culture or NAATs are not available, antigen detection--a direct immunofluorescence test or enzyme immunoassay from samples from symptomatic patients--could be employed, but HSV type determination is of importance; (iii) only type-specific serology should be used for detecting asymptomatic individuals, testing pregnant women at risk of acquiring HSV infection close to delivery, men who have sex with men and people who are HIV positive; (iv) widespread screening for HSV antibodies should be discouraged; and (v) any non-validated diagnostic tests should be validated against a recommended, approved gold standard.

An immunofiltration device for the simultaneous detection of non-treponemal and treponemal antibodies in patients with syphilis.

OBJECTIVE: The development of a rapid immunofiltration (flow-through) test for the simultaneous detection of non-treponemal and treponemal antibodies in the serum of patients with syphilis. METHODS: The assay is rapid, inexpensive, and requires limited expertise in interpreting the results. The test is based on the principle of immunofiltration, with two antigens and control material spotted on the membrane of a through-flow device. A positive test is characterised by the appearance of three red/magenta spots within 2-10 min. RESULTS: A total of 376 banked serum samples obtained from the Georgia Public Health Laboratory was examined by the flow-through test, the rapid plasma reagin (RPR) test and the Treponema pallidum passive particle agglutination assay (TPPA). The sensitivity and specificity of the non-treponemal spot were 96.5% and 97.7%, respectively, when compared with the RPR test, and the sensitivity and specificity of the treponemal test spot were 97.3% and 99.1% when compared with the TPPA test. In addition, the test yielded equivalent results to those obtained in comparator tests when 104 sera from cases of syphilis of known stage, 49 sera from diseases other than syphilis and 23 sera known to exhibit biological false-positive reactions were tested in parallel. CONCLUSIONS: These results indicate that the dual treponemal and non-treponemal assay could be used as a screen and confirmatory test for the serological diagnosis of syphilis in remote or resource-poor settings where there is a need to provide counselling and treatment at the initial consultation.

Guidelines for the laboratory diagnosis of trichomoniasis in East European countries.

The laboratory diagnosis of sexually transmitted infections in many Eastern European countries remains suboptimal. The main objective of the present evidence-based guidelines is to provide comprehensive information regarding the laboratory diagnosis of infections caused by Trichomonas vaginalis in East European countries. In particular, the present guidelines recommend: (i) to encourage examination of the wet mounts of vaginal exudates, instead of stained smears, at all clinical settings; (ii) nucleic acid amplification tests (NAATs) or culture could be employed if no trichomonads are detected on microscopic examination of the wet preparation and there is a strong indication of infection and (iii) the use of NAATs is encouraged in screening, using non-invasive specimens, or high volume testing situations. In the absence of internationally recognized commercial NAAT systems, tests developed in-house should be validated using obtainable international standards and quality assured strictly. Individual East European countries may be required to make minor national adjustments to these guidelines as a result of lack of accessibility to some reagents or equipment, or laws in a specific country.

Laboratory support for the diagnosis and surveillance of sexually transmitted infections (STIs) in Eastern Europe.

This report outlines the proceedings of the 4th Annual Meeting of the Eastern European Network for Sexual and Reproductive Health (EE SRH Network) [1,2], which took place at Uppsala University in Uppsala, Sweden between 30 May and 3 June, 2009.

Guidelines for the laboratory diagnosis of Chlamydia trachomatis infections in East European countries.

The present guidelines aim to provide comprehensive information regarding the laboratory diagnosis of infections caused by Chlamydia trachomatis in East European countries. These recommendations contain important information for laboratory staff working with sexually transmitted infections (STIs) and/or STI-related issues. Individual East European countries may be required to make minor national adjustments to these guidelines as a result of lack of accessibility to some reagents or equipment, or laws in a specific country.

Laboratory diagnostics for non-viral sexually transmitted infections in St. Petersburg, Russia: current situation and hallmarks for improvements.

BACKGROUND: The numbers and performance characteristics of laboratories providing sexually transmitted infection (STI) diagnostic services, as well as the rates of morbidity due to STIs in St. Petersburg, Russia, remain largely unknown. OBJECTIVE: The aim of the present study was to evaluate the range, quality and availability of diagnostic services for several non-viral STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Trichomonas vaginalis) in St. Petersburg during the period September 2005 to June 2006. METHODS: Survey data focusing on organization and performance characteristics of STI diagnostic services were assessed using questionnaires, telephone interviews and site visits. RESULTS: A total of 118 laboratories providing STI diagnostic services were identified. Of the surveyed laboratories, 54% (64 of 118) diagnosed syphilis, 81% (96 of 118) gonorrhoea, 80% (94 of 118) trichomoniasis and 49% (58 of 118) chlamydial infections. Although most of the laboratories could provide a presumptive diagnosis for syphilis, most of the N. gonorrhoeae and T. vaginalis testing of women did not adhere to international recommendations. Of the laboratories with the capacity to diagnose C. trachomatis infection, 69% still used serological testing (enzyme-linked immunosorbent assay) to detect antibodies to C. trachomatis. CONCLUSIONS: Overall, the diagnostic methods used to establish a laboratory diagnosis, the system of case reporting, the training of laboratory personnel and the level of interlaboratory communication clearly require improvement. This study represents the first step in a process of evaluation of the laboratory support for STI services and the establishment of an interlaboratory network in St. Petersburg.

A real-time quadriplex PCR assay for the diagnosis of rectal lymphogranuloma venereum and non-lymphogranuloma venereum Chlamydia trachomatis infections.

OBJECTIVES: To develop and evaluate a real-time quadriplex PCR for the diagnosis of lymphogranuloma venereum (LGV) and non-LGV chlamydial infections using rectal swab specimens. METHODS: The design of the real-time quadriplex PCR assay incorporates an LGV-specific, a non-LGV-specific target sequence, a Chlamydia trachomatis plasmid target, and the human RNase P gene as an internal control. The performance of the quadriplex PCR was compared with a previously reported real-time duplex PCR assay on which LGV diagnosis was based on exclusion. RESULTS: Very good agreement (85 of 89 specimens, 95.5%) was found between the two multiplex PCR assays for the detection of C trachomatis DNA (kappa value 0.93, 95% CI 0.86 to 0.99). Both assays identified 34 LGV, 35 non-LGV C trachomatis and 16 negative specimens. Of two specimens that tested positive for non-LGV by the duplex PCR, one was found to be a mixed infection and the other was positive only for plasmid and RNase P targets by the quadriplex PCR. Two additional specimens that had equivocal results for non-LGV by the duplex PCR also tested positive only for plasmid target and human DNA by the quadriplex PCR. In addition, six specimens that tested negative by the duplex PCR assay were found to be invalid when using the quadriplex PCR. CONCLUSIONS: A real-time quadriplex PCR assay has been developed that is capable of detecting LGV, non-LGV, or mixed infections simultaneously in rectal specimens. The assay also contains a supplemental amplification target for the confirmation of C trachomatis infection as well as a human DNA control for monitoring sample adequacy and PCR inhibition.

Comparison of a TaqMan-based real-time polymerase chain reaction with conventional tests for the detection of Trichomonas vaginalis.

OBJECTIVE: To compare a TaqMan-based real-time polymerase chain reaction (PCR) with conventional PCR, culture, and wet-mount microscopy for the diagnosis of trichomoniasis in women. METHODS: Vaginal swabs from 119 women were tested for Trichomonas vaginalis by wet mount and culture. Paired vaginal lavage and urine specimens were tested by conventional and real-time PCR. RESULTS: Using an expanded "gold standard", defined as a positive culture result using vaginal swabs and/or a positive PCR test using TVK3/7 primers, the overall prevalence of T vaginalis in the study population was 65.5% (78/119). The detection rate of T vaginalis was 65.5% (78/119) and 36.9% (44/119) by conventional PCR using vaginal washings and urine specimens, respectively; 68.9% (82/119) by real-time PCR using vaginal washings and 61.3% (73/119) by real-time PCR using urine specimens. The sensitivities of conventional PCR using vaginal washings and urine and real-time PCR using vaginal washings and urine, compared with the gold standard were 100%, 56.4%, 100% and 76.7%, and the specificities of these tests were 100%, 97.6%, 82.9% and 97%, respectively. CONCLUSIONS: The real-time PCR test proved to be significantly more sensitive than culture and wet-mount microscopy, although its specificity was slightly lower than these tests. In addition, it was more sensitive, rapid and less time consuming than conventional PCR for the detection of T vaginalis.

The influence of concomitant HIV infection on the serological diagnosis of primary syphilis in southern Africa.

The authors investigated the utility of both a nontreponemal (RPR) test and a treponemal (FTA-ABS) test for the diagnosis of primary syphilis during the emergence of the HIV epidemic in southern Africa. The serological tests were performed on 868 patients with genital ulcerations, seen in five centres. While primary syphilis was diagnosed by multiplex PCR in 163 cases (18.8%), the overall RPR and FTA-ABS seroprevalences were 24.3% and 51.5% respectively. The sensitivities of the RPR and FTA-ABS to detect primary syphilis were 69.3% and 89.6% respectively, while the specificities were 86.1% and 58.5% respectively. The performance characteristics of these tests were influenced negatively by concomitant HIV infection and the presence of other genital ulcer disease pathogens in lesions found to be Treponema pallidum PCR positive.

Changes in the patterns of sexually transmitted infection among South African mineworkers, associated with the emergence of the HIV/AIDS epidemic.

OBJECTIVE: To study temporal changes in the relative prevalence of STI syndromes and the aetiology of genital ulcer disease (GUD) among migrant mineworkers in a goldmining area in South Africa during the period 1992 - 2000 and to explore the epidemiological synergy and interactions between these conventional STIs and the emergence of HIV infection. METHOD: The records of all STI patients presenting with new episodes of STI seen at a dedicated STI clinic in the Carletonville area, near Johannesburg, between 1992 and 2000 were reviewed and analysed. In addition, crosssectional studies to determine the aetiology of genital ulcerations were conducted. RESULTS: During the study period, 36 686 new STI episodes were treated at the clinic with a mean annual STI incidence rate of 137.4 per 1 000 miners. The STI incidence remained high throughout the period 1994 - 1999. A total of 35 789 HIV tests were performed during the study period; the overall HIV prevalence was 35.3%. Between 1986 and 1994, the relative prevalence of genital herpes rapidly increased among GUD patients co-infected with HIV: 0% in 1986, 4.7% in 1990 and 20.8% in 1994. CONCLUSIONS: Syndromic and microbiological surveillance indicates that there was a high incidence of non-herpetic genital ulcerations among miners during the early phase of HIV epidemic. This sustained high incidence of GUDs was followed by a rapid increase in HIV prevalence and changes in the aetiology of the STI syndrome.

A multi-centre evaluation of nine rapid, point-of-care syphilis tests using archived sera.

OBJECTIVES: To evaluate nine rapid syphilis tests at eight geographically diverse laboratory sites for their performance and operational characteristics. METHODS: Tests were compared "head to head" using locally assembled panels of 100 archived (50 positive and 50 negative) sera at each site using as reference standards the Treponema pallidum haemagglutination or the T pallidum particle agglutination test. In addition inter-site variation, result stability, test reproducibility and test operational characteristics were assessed. RESULTS: All nine tests gave good performance relative to the reference standard with sensitivities ranging from 84.5-97.7% and specificities from 84.5-98%. Result stability was variable if result reading was delayed past the recommended period. All the tests were found to be easy to use, especially the lateral flow tests. CONCLUSIONS: All the tests evaluated have acceptable performance characteristics and could make an impact on the control of syphilis. Tests that can use whole blood and do not require refrigeration were selected for further evaluation in field settings.

The epidemiology of HIV-1 infection in northern Tanzania: results from a community-based study.

We conducted a community-based study to determine the predictors of HIV-1 among women aged 20-44 years (N = 1,418) and their regular male partners (N = 566) from randomly selected households in Moshi, Tanzania. The weighted prevalence of HIV-1 was 10.3% in women and 7% in men. The highest risk of HIV-1 was in subjects whose partners were HIV-1 seropositive in both women (adjusted odds ratio (AOR) = 26.63; 95% confidence interval (CI): 10.74-66.02) and men (AOR = 22.25; 95%CI: 7.06-70.15). Herpes simplex virus type 2 (HSV-2) and Mycoplasma genitalium were also significantly associated with HIV-1. Women with male partners >or=12 years older than themselves had increased risk of HIV-1 (AOR = 1.99; 95%CI: 1.01-7.85). Other predictors of HIV-1 were history of infertility and the number of sex partners in the last three years in women and the age at time of circumcision and history of past sexually transmitted diseases (STDs) in male partners. These findings show that HIV-1/STDs were major public health problems among women and their long-term partners in this population. HIV-1 prevention efforts should include promotion of couple's HIV-1 counseling and testing services, control of HSV-2, promotion of safer sexual practices and strategies to reduce the age difference between women and their partners.

Risk factors for HIV infection among sex workers in Johannesburg, South Africa.

Our objective was to determine the prevalence and risk factors for HIV infection among female sex workers in Johannesburg, South Africa. A cross-sectional survey of female sex workers was conducted using interviewer-administered questionnaires. Prevalent sexually transmitted infections including HIV were evaluated through standard laboratory testing. HIV infection was identified in 137 (46.4%) of 295 subjects tested. Increasing frequency of condom use was significantly negatively associated with HIV infection (odds ratio [OR] for moderate use = 0.21; 95% confidence interval [CI]: [0.09, 0.50]; OR for high use = 0.14; 95% CI: [0.06, 0.34]). Sex workers aged > or = 29 years reported significantly different patterns of behaviour than younger workers. Among women aged > or = 29, a negative association with HIV infection (OR = 0.16; 95% CI: [0.07, 0.38]) was found, but only among those not infected with Neisseria gonorrhoeae. Older women in the Johannesburg sex industry may have adaptive behavioural strategies besides condom usage which reduce their risk of acquiring HIV. However, older sex workers with gonorrhoea constitute a high-risk subgroup.

Evaluation of Xenostrip-Tv, a rapid diagnostic test for Trichomonas vaginalis infection.

An immunochromatographic strip test, Xenostrip-Tv, was compared to wet mount and PCR for the diagnosis of Trichomonas vaginalis infection in women. Of 428 specimens tested, 54 (12.6%) were positive by an "expanded gold standard," defined as either a positive wet mount and PCR test with primers TVK3 and TVK7 and/or a positive PCR test confirmed by a second PCR assay with primers TVA5-1 and TVA6; 26 (6%) were positive by wet mount, and 36 (8.4%) were positive by Xenostrip-Tv test. Since the Xenostrip-Tv test is rapid and easy to perform and proved to be more sensitive than wet mount, it should be considered as an alternative to wet mount for point-of-care diagnosis of trichomoniasis, especially in settings where microscopy is impractical.

Increasing relative prevalence of HSV-2 infection among men with genital ulcers from a mining community in South Africa.

OBJECTIVES: To determine the aetiology of genital ulcer disease (GUD) and its association with HIV infection in the mining community of Carletonville, South Africa, from two cross sectional surveys of consecutive men presenting with genital lesions during October 1993 to January 1994 and July to November 1998. METHODS: A multiplex polymerase chain reaction (M-PCR) assay combined with amplicon detection was used to identify DNA specific sequences of Treponema pallidum, herpes simplex virus (HSV), and Haemophilus ducreyi. A real time PCR assay was used to differentiate between HSV-1 and HSV-2. RESULTS: M-PCR detected T pallidum, HSV, and H ducreyi in 10.3%, 17.2%, and 69.4% of 232 GUD patients during 1993-4 and in 12.4%, 36.0%, and 50.5% of 186 GUD patients in 1998. The proportion of patients with more than one agent increased significantly from 7.3% (17/232) in 1993-4 to 16.7% (31/186) in 1998 (p <0.01). HSV-2 was detected in a higher proportion of ulcer specimens from HIV infected patients than in specimens from HIV uninfected patients during both time periods (1993-4: 26.2% v 6.7%, p <0.001; 1998: 42.1% v 29.6%, p >0.09). CONCLUSIONS: Based on two cross sectional surveys, 4 years apart, chancroid remained the leading cause of GUD in men who presented at the STD clinic with genital ulcers in the mining community of Carletonville, South Africa. The relative prevalence of primary syphilis has remained low. However, HSV-2 has emerged as a more significant cause of GUD and the proportion of GUD patients infected with more than one agent also increased significantly. HSV-2 DNA was detected in a significantly higher proportion of ulcer specimens from HIV positive patients than from HIV negative patients. No association was found between HIV infection status and the relative prevalence of chancroid or syphilis.

Coexistence of urethritis with genital ulcer disease in South Africa: influence on provision of syndromic management.

OBJECTIVE: To assess whether syndromic management of genital ulcer disease was sound, if based on the premise that men with genital ulcers rarely have a concomitant urethral infection. METHODS: Specimens were taken in 1998 from 186 mine workers in Carletonville, South Africa, who were seen consecutively with genital ulcers. The specimens comprised a swab from the ulcer, a urethral swab for a Gram stained smear, and 10-15 ml of a first catch urine sample. The latter was tested by ligase chain reaction assays for Neisseria gonorrhoeae and Chlamydia trachomatis specific DNA sequences and by a polymerase chain reaction (PCR) assay for Mycoplasma genitalium. Ulcer inducing micro-organisms were detected either by a multiplex PCR assay, or in the case of lymphogranuloma venereum (LGV) serologically, and human immunodeficiency virus (HIV) infection was detected by an enzyme linked immunosorbent assay (ELISA) test. RESULTS: Most (54%) of the ulcers were chancroidal, 18% were herpetic (HSV type 2), 6.5% primary syphilitic, and 3.2% due to LGV. More than one micro-organism was detected in 9.1% of the ulcers and less than 10% were undiagnosed. Microscopic examination of the urethral smears showed that 99 (53%) of the men had urethritis, of whom 45 (45%) were infected with N gonorrhoeae. Of the 54 men (55%) who had non-gonococcal urethritis (NGU), 11 (19.6%) harboured C trachomatis or M genitalium. Almost two thirds (64.5%) of the men had HIV infection, but this did not seem to have influenced the aetiology of the ulcers. Nor was a particular ulcer associated with one type of urethritis more than the other. Neither C trachomatis nor M genitalium was associated significantly with non-gonococcal urethritis (NGU) in either HIV positive or HIV negative men. CONCLUSION: The combination of antibiotics used for the management of genital ulcer disease in men in this South African mining population needs to be widened to encompass frequently occurring concomitant gonococcal urethritis and NGU infections. This means treatment with long acting penicillin, combined with ciprofloxacin and azithromycin or erythromycin. A similar situation may exist in other geographical locations with a need to provide appropriate antimicrobial combinations depending on the patterns of infection detected.

Observations on the microbiology of urethritis in black South African men.

The occurrence of Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium was determined by molecular techniques in urine specimens from 182 black South African men who had symptoms and/or overt signs of urethritis. Eighty-six (47.3%) of these men were infected with N. gonorrhoeae. There were 185 men without overt evidence of urethritis, 16 (8.6%) of whom were also infected with N. gonorrhoeae. Of the 96 men who had non-gonococcal urethritis, 14 (14.6%) were infected with C. trachomatis, 16 (16.7%) with M. genitalium and only one with both microorganisms. In comparison, 15 (8.9%) of 169 men without overt urethritis and without N. gonorrhoeae were infected with C. trachomatis and 15 (8.9%) with M. genitalium, proportions that were about half the size of those in the group with overt urethritis.

Molecular typing of Treponema pallidum in South Africa: cross-sectional studies.

We evaluated a molecular subtyping system for Treponema pallidum for its ability to differentiate between strains obtained from male patients with primary syphilis in South Africa. Of 201 T. pallidum-positive specimens, 161 were typeable, revealing 35 subtypes. The unique subtypes identified in Durban, Cape Town, and Carletonville and the total number of subtypes suggested that the strain population was very diverse and varied geographically.

STD care in the South African private health sector.

OBJECTIVES: To establish the accessibility and quality of sexually transmitted disease (STD) care provided by private general practitioners (GPs) and workplace health services in South Africa. DESIGN: Structured telephone interviews were conducted with a random national sample of 120 GPs and 244 occupational health nurses (OHNs) between May and July 1997. The interview schedules covered indicators of access (including utilisation) and processes (drug treatment, partner management, counselling and condom promotion) of STD care. RESULTS: An estimated 5 million STD-related visits were made to private general practices in 1997. Reported treatment of STDs was assessed for effectiveness using well-established syndromic case management guidelines. Only 28% of GPs reported effective treatment for urethral discharge. This dropped to 14% for genital ulcer and 4% for pelvic inflammatory disease. Fifty-five per cent of the OHNs interviewed indicated that their workplace clinics provided STD care. Nurses provided this care, with or without the support of doctors, in 87% of clinics. Reported urethral discharge and genital ulcer treatment regimens were assessed as effective in 34% and 14% of responses, respectively. CONCLUSIONS: The private sector is a major provider of STD care and is key to national efforts to achieve better STD control, thereby preventing the spread of HIV. However, the results of the research suggest that the poor quality of STD care may be undermining attempts to control these epidemics in our society. Although a complex task, strategies need to be found to improve the quality of care provided within the private sector.