Periodical antibiotic treatment for the control of gonococcal and chlamydial infections among sex workers in Benin and Ghana: a cluster-randomized placebo-controlled trial.

BACKGROUND: In resource-poor settings, control of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) among female sex workers (FSWs) is difficult. We sought to determine whether periodical antibiotic treatment (PAT) might be effective in controlling these infections among West African FSWs. Secondary objectives were to determine the impact of PAT on human immunodeficiency virus (HIV) incidence among FSWs and on NG/CT prevalence among their clients. METHODS: Cluster-randomized, double-blind, placebo-controlled trial among FSW communities in Benin and Ghana. Within each of 9 pairs of clusters of FSW communities, one was allocated to receive, during 9 months, a monthly antibiotic (alternatively ciprofloxacin or azithromycin, n = 296 FSWs) and the other a placebo (n = 340 FSWs). Prevalence of NG/CT infections was measured at 3-month intervals using the polymerase chain reaction. HIV status was determined at the beginning and at the end of the study. RESULTS: After adjusting for age, HIV status, duration of prostitution, price per intercourse and condom use, and accounting for prevalence at enrollment and cluster-pairing effect, prevalence ratios (intervention vs. placebo) of NG infection were 0.77 (P = NS), 1.07 (P = NS), and 0.49 (P = 0.05) at the first, second, and third follow-up visits, respectively. PAT neither reduced significantly CT prevalence or HIV incidence among FSWs nor NG/CT prevalence among their clients. CONCLUSION: The only beneficial impact of PAT was on the prevalence of gonococcal infections among FSWs 9 months after the beginning of the intervention. Although PAT could be more effective in other circumstances, for instance, in the early stages of a program for FSWs, it can not be recommended at present as a routine strategy to control cervical infections among FSWs.

The complex vaginal flora of West African women with bacterial vaginosis.

BACKGROUND: The spectrum of bacteria associated with bacterial vaginosis (BV) has recently expanded through taxonomic changes and the use of molecular methods. These methods have yet to be used in large-scale epidemiological studies in Africa where BV is highly prevalent. METHODS: An analysis of samples obtained during a clinical trial of the management of vaginal discharge in four West African countries. Samples were available from 1555 participants; 843 (54%) had BV. Nucleic acids of 13 bacterial genera or species potentially associated with BV were detected through the polymerase chain reaction. RESULTS: The associations between various components of the vaginal flora were complex. Excluding Lactobacillus, the other 12 micro-organisms were all associated with each other at the p≤0.001 level. The prevalence of various bacterial genera or species varied according to age, sexual activity and HIV status. In multivariate analysis, the presence of Gardnerella vaginalis, Bifidobacterium, Megasphaera elsdenii, Dialister, Mycoplasma hominis, Leptotrichia, and Prevotella were independently associated with BV as was the absence of Lactobacillus and Peptoniphilus. However, Mobiluncus, Atopobium vaginae, Anaerococcus, and Eggerthella were not independently associated with BV. Unexpectedly, after treatment with a regimen that included either metronidazole or tinidazole, the proportion of patients with a complete resolution of symptoms by day 14 increased with the number of bacterial genera or species present at enrolment. CONCLUSIONS: Numerous bacterial genera or species were strongly associated with each other in a pattern that suggested a symbiotic relationship. BV cases with a simpler flora were less likely to respond to treatment. Overall, the vaginal flora of West African women with BV was reminiscent of that of their counterparts in industrialized countries.

Performance of the BioPlex 2200 multiplexing immunoassay platform for the detection of herpes simplex virus type 2 specific antibodies in African settings.

The BioPlex platform was evaluated for the detection of herpes simplex virus 2 (HSV-2) antibodies in sub-Saharan Africa individuals in comparison to clinicovirological standards and compared to HerpeSelect. The sensitivities and specificities were, respectively, 88.9% and 93.5% for BioPlex and 89.9% and 92.7% for HerpeSelect. The agreement between both assays was 95.7%.

The syndromic management of vaginal discharge using single-dose treatments: a randomized controlled trial in West Africa.

OBJECTIVE: To evaluate whether single-dose treatments are as effective as standard therapy in the syndromic management of vaginal discharge. METHODS: A randomized controlled effectiveness trial compared single-dose tinidazole plus fluconazole (TF) with treatment for 7 days with metronidazole plus 3 days of treatment with vaginal clotrimazole (MC) among 1570 women presenting with vaginal discharge at primary health care institutions in Ghana, Guinea, Mali and Togo. Participants were randomly allocated to one of the two treatments by research nurses or physicians using precoded envelopes. Effectiveness was assessed by symptomatic response on day 14. CLINICAL IDENTIFIER ClinicalTrials.gov NCT00313131. FINDINGS: The two treatment regimens had similar effectiveness: complete resolution was seen in 66% (TF) and 64% (MC) and partial resolution in 33% (TF) and 34% (MC) of participants (P = 0.26). Effectiveness was similar among subgroups with vulvovaginal candidiasis, Trichomonas vaginalis vaginitis or bacterial vaginosis. The two treatment regimens had a similar effectiveness among human immunodeficiency virus (HIV)-infected (TF: n = 76, 71% complete resolution, 28% partial; MC: n = 83, 72% complete resolution, 25% partial, P = 0.76) and HIV-uninfected women (TF: n = 517, 68% complete, 32% partial; MC: n = 466, 65% complete, 33% partial, P = 0.20). Cervical infections with Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium were uncommon among women not involved in sex work, were associated with bacterial vaginosis or T. vaginalis vaginitis, and did not alter response to treatment with agents active against vaginal infections. Four-fifths of women not relieved by a single dose of TF had a favourable response when MC was administered as second-line treatment. CONCLUSION: Single-dose TF is as effective as multiple-dose MC in the syndromic management of vaginal discharge, even among women with HIV-infection. Given its low price and easier adherence, TF should be considered as a first-line treatment for vaginal discharge syndrome.

Improving second-generation surveillance: the biological measure of unprotected intercourse using prostate-specific antigen in vaginal secretions of West African women.

BACKGROUND: Second-generation surveillance for HIV includes measures of high-risk behaviors among the general adult population and sex workers (SW). Questionnaires are prone to social desirability biases because individuals minimize the frequency of behaviors not expected from them. OBJECTIVE: Determine whether the prostate-specific antigen (PSA) could be used as a biological marker of unprotected intercourse. METHODS: We measured the presence of PSA in vaginal secretions of women who were (n = 508) or were not (n = 658) SW presenting with vaginal discharge in health facilities of Ghana, Togo, Guinea, and Mali. The cutoff for a positive assay was determined as > or =0.4 microg/L based on a subsample of 95 non-SW claiming abstinence for 3 months. RESULTS: A positive PSA assay was correlated with infections with Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium. Among non-SW, a positive PSA was more common among those with HIV, but less frequent in those better educated. Among SW and non-SW, women from Ghana were less likely to have a positive PSA and had a lower prevalence of sexually transmitted infections than those from elsewhere. CONCLUSIONS: PSA can be used as a biological marker of unprotected intercourse, allowing interventions to target efforts on those at highest risk.

Real-time PCR quantification of genital shedding of herpes simplex virus (HSV) and human immunodeficiency virus (HIV) in women coinfected with HSV and HIV.

The accuracy and usefulness of laboratory-developed real-time PCR procedures using a Light Cycler instrument (Roche Diagnostics) for detecting and quantifying human immunodeficiency virus type 1 (HIV-1) RNA and DNA as well as herpes simplex virus type 1 (HSV-1)/HSV-2 DNA in cervicovaginal secretions from women coinfected with HIV and HSV were evaluated. For HIV-1, the use of the NEC152 and NEC131 primer set and the NEC-LTR probe in the long terminal repeat gene allowed us to detect accurately the majority of HIV-1 subtypes of group M circulating in sub-Saharan Africa, including subtypes A, B, C, D, and G as well as circulating recombinant forms 02 and 11. The detection threshold of real-time PCR for HIV in cervicovaginal lavage samples was 5 copies per assay for both RNA and DNA; the intra- and interassay coefficients of variation of C(T) values were 1.30% and 0.69% (HIV-1 RNA) and 1.84% and 0.67% (HIV-1 DNA), respectively. Real-time PCR for HSV using primers and probe targeting the HSV DNA polymerase gene allowed both detection and quantification of HSV DNA and also differentiation between HSV-1 and HSV-2 genotypes. The detection threshold of real-time PCR for HSV was 5 copies per assay; the intra- and interassay coefficients of variation of C(T) values were 0.96% and 1.49%, respectively. Both manual and automated silica-based procedures were appropriate for combined extraction of HIV and HSV genomes from female genital secretions. Taken together, these findings indicate that real-time PCR may be used as a unique nucleic acid amplification procedure to detect and quantify HIV and HSV genomes in cervicovaginal secretions and thus to assess at reduced costs the genital shedding of both viruses in women included in intervention studies.

The price of development: HIV infection in a semiurban community of Ghana.

OBJECTIVE: To describe the epidemiology of HIV infection in the Manya Krobo District, Ghana, and its potential link to the building of the Akosombo dam. METHODS: A questionnaire and a blood sample were collected among 1228 consecutive pregnant women seen at the prenatal clinics of the two major hospitals of the district. RESULTS: Overall, prevalence of HIV and of serologically confirmed syphilis were 14.9% and 0.7%, respectively. HIV infection was more prevalent among the Krobo ethnic group (137 of 742 [18.5%]) than among other ethnic groups (46 of 486 [9.5%]; p <.001). Two distinct patterns of HIV distribution were identified. Among the Krobos, HIV was common among all age groups, reached a plateau (21.9%) in the 30- to 34-year-old group and was associated strongly with having lived in Côte d'Ivoire and with having received only primary school education. Among the other ethnic groups, prevalence decreased with age, from 17.2% in the 13- to 19-year-old age group to 1.4% among women aged 35 years or older, and HIV infection was associated with having had first sexual intercourse before the age of 17 years. In logistic regression analysis, the independent risk factors for HIV infection were age, schooling, age at first sexual intercourse; having lived in Côte d'Ivoire; age and schooling showed significant interactions with ethnic group. CONCLUSIONS: The high HIV prevalence documented in this part of Ghana seems to be, to some extent, a consequence of construction of the Akosombo dam in the 1960s. The flooding of the land, the failures of the resettlement program and the ensuing poverty prompted economically driven migration, specially to Côte d'Ivoire, where many migrants became infected with HIV. Local transmission followed. This illustrates that HIV can disseminate widely in a society where most men are circumcised and where genital ulcerative diseases are uncommon and should be an indication for less complacency about HIV control in West Africa.