Risk factors for gonococcal and chlamydial cervical infection in pregnant and non-pregnant women in Zimbabwe.

OBJECTIVE: To identify demographic, behavioural and clinical characteristics of symptomatic and asymptomatic women with gonococcal and/or chlamydial cervicitis a study was conducted among women attending antenatal clinics and primary care clinics in Harare, Zimbabwe. DESIGN: Cross sectional study. SETTING: Primary care clinics and antenatal clinics in Harare. SUBJECTS: 467 women with vaginal discharge and 1,189 asymptomatic pregnant women. MAIN OUTCOME MEASURES: Behavioural and clinical correlates of gonococcal and chlamydial cervical infection. RESULTS: The mean age of symptomatic women was 26.11 +/- 6.84 years (range: 15 to 52 years) and that of asymptomatic pregnant women was 24.67 +/- 5.43 years (range: 15 to 45 years). Gonococcal and/or chlamydial cervical infection was found in 69 of 1,189 (5.8%) pregnant women and in 77 of 467 (16.5%) non-pregnant women. Logistic regression analysis identified the following predictors of gonococcal or chlamydial infection in women with vaginal discharge: being separated from the partner for a month or more (p = 0.002), having had sex with a new partner in the last three months (p = 0.002), current use of condoms (p = 0.011), and the finding on examination of a purulent vaginal discharge (p = 0.004). Amongst these women an increasing educational level was inversely associated with cervical infection (p = 0.007). Amongst asymptomatic pregnant women the following were identified as predictors of cervical infection: the patient admitting to having a vaginal discharge on direct questioning (p = 0.004), and the finding of a purulent vaginal discharge on examination (p = 0.001). CONCLUSIONS: Amongst symptomatic and asymptomatic women certain behavioural factors and some clinical findings are associated with cervical gonococcal or chlamydial infection. Women with multiple partners and with partners who are currently using condoms with them and those women with a purulent vaginal discharge are likely to be infected. The age and marital status of subjects was not associated with cervical infection. These findings are useful in providing appropriate care for women with overt or minimal symptoms.

Antimicrobial resistance in gonococci isolated from patients and from commercial sex workers in Harare, Zimbabwe.

The objective is to compare antibiotic resistance amongst gonococci isolated from different patient groups in Harare, Zimbabwe. Antimicrobial susceptibilities of Neisseria. gonorrhoeae were determined by disc sensitivity tests. The MICs for penicillin, kanamycin, ceftriaxone, norfloxacin and ciprofloxacin were determined using E-test strips. There were 147 isolates from symptomatic men, 47 isolates from symptomatic women, 29 isolates from asymptomatic women and 41 isolates from female commercial sex workers. A total of 119 (45%) isolates were PPNG and 23 (16%) non-PPNG isolates had a penicillin MIC > 0.64 mg/l. Over 90% of isolates were resistant to TMP/SMX and 16% were resistant to tetracycline. Resistance was uncommon against kanamycin (6%), erythromycin (2%) or ceftriaxone ( < 1%). For kanamycin, the MIC90 was 32 mg/l, for ceftriaxone the MIC90 was < 0.032 mg/l for non-PPNG and < 0.064 mg/l for PPNG. For norfloxacin and ciprofloxacin the MIC90 was < 0.064 mg/l for both PPNG and non-PPNG. Isolates from the commercial sex workers showed a significantly increased prevalence of PPNG, of penicillin-tolerant non-PPNG and of tetracycline resistance. Four of the 41 isolates from sex workers showed multiple resistance (to penicillin, TMP/SMX, tetracycline and kanamycin) compared to 1/223 isolates from other groups (OR = 24.0). Antimicrobial resistance is common amongst gonococci in Harare, especially with isolates from commercial sex workers. In order for STD treatment to be implemented as an effective strategy in HIV control, continued monitoring of resistance patterns is essential.

Reduced semen quality and risk behaviour amongst men consulting a referral STD clinic.

Sexually transmitted diseases (STDs) and infertility are public health challenges that continue to represent a high demand and costly adult medical care conditions in most developing countries. Few studies address strategies for prevention of infertility secondary to STDs through behavioural change and early and prompt STD treatment. A prospective cohort design was used to study the effects of urogenital infection on semen quality in consenting consecutive subjects that presented with chronic or recurrent sexually transmitted diseases. Health seeking behavioural correlates and socio-economic variables were compared between index subjects at a genito-urinary referral clinic and those that presented with non-STD conditions at a referral polyclinic.

Genital infections in women attending a genito-urinary clinic in Harare, Zimbabwe.

One hundred women attending a sexually transmitted diseases clinic in Harare were examined for presenting features and genital infections. The most common presenting symptoms were of discharge, lower abdominal pain and dysuria, and on examination signs of discharge, inflammation, haemorrhage or ulcers/erosions were noticeable in all women. Fourteen women had genital warts. Pathogens were detected in 95% of patients. Gonococcal infection occurred in 19 women, with 60% of the strains isolated being penicillinase producing. Yeasts were detected in specimens from 25 women while chlamydial infection appeared to be rare, evidence of infection being detected in only eight women. Sera from 44 women were positive by the RPR test and sera from 33 women were positive by TPHA. Gardnerella vaginalis was isolated from 48 women, Group B streptococci from 37 women, and Trichomonas vaginalis from 32 women.

Antimicrobial susceptibility of Neisseria gonorrhoeae in Harare, Zimbabwe. Relationship to serogroup.

The authors investigated one hundred fifty-four isolates of Neisseria gonorrhoeae obtained from men, women, and infants in Harare, Zimbabwe, for in vitro susceptibility to various antibiotics and for reactivity with serogrouping antisera. The authors found sixty-four (42%) isolates to be WI serogroup and 90 (58%) to be WII/III. One hundred three isolates were penicillinase-producing N. gonorrhoeae (PPNG); although all of these showed resistance to penicillin, 14 isolates had an MIC to penicillin of less than 10 mg/L. All of these 14 isolates were WI serogroup. Twenty-seven of the 51 non-PPNG showed in vitro resistance to penicillin (MIC greater than 1.25 mg/L). All but one of these chromosomally resistant isolates were WII/III serogroup. With cefuroxime, tetracycline, and erythromycin, 10-15% of isolates had MICs greater than accepted breakpoints. Most isolates were susceptible to thiamphenicol, and all were susceptible to ciprofloxacin, kanamycin, and spectinomycin. The authors noted that WI isolates, whether PPNG or not, were consistently more susceptible to antibiotics than WII/III isolates. Only with kanamycin and spectinomycin were the MICs of the two serogroups similar.

Clinical and laboratory characteristics of HIV-1 infection in Zimbabwe.

To define the impact of human immunodeficiency virus (HIV) infection in Africa, clinical and laboratory investigations were conducted on 265 HIV-seropositive outpatients in Zimbabwe. Twenty-four of the study subjects were asymptomatic (ASX), 124 had persistent generalized lymphadenopathy (PGL), and 117 had AIDS-related complex (ARC). HIV infection was assessed by commercial ELISA, Western blots, synthetic peptide ELISA, and measurement of p24 antigen. Serum immunoglobulins, lymphocyte mitogen responses, and CD4+ cell numbers were obtained in 54 sequential patients. Compared to seronegative subjects, mean CD4+ cell numbers were decreased and serum immunoglobulins, particularly IgM and IgG, were increased in all groups of seropositive subjects. Lymphocyte proliferative responses to phytohemagglutinin and concanavalin A decreased progressively in ASX, PGL, and ARC patients and were significantly lower in PGL and ARC patients compared to seronegative controls. Generalized lymphadenopathy was present in 234/265 (88%) of patients. Lymph node biopsies in 100 patients demonstrated follicular hyperplasia in 97 and Mycobacterium tuberculosis in 3. Of 165 patients followed for a median of 6 months, 5 developed the acquired immune deficiency syndrome (AIDS). Symptoms of ARC, low CD4+ cell number, and p24 antigen were predictive of the development of AIDS in Zimbabwe.

Clinical and laboratory characteristics of HIV-1 infection in Zimbabwe

To define the impact of human immunolodeficiency virus (HIV) infection in Africa; clinical and laboratory investigations were conducted on 265 HIV-seropositive outpatients in Zimbabwe. Twenty-four of the study subjects were asymptomatic (ASX); 124 had persistent generalized lympademopathy (PGL); and 117 had AIDS-related complex (ARC). HIV infection was assessed by commercial ELISA; Western blots; synthetic peptide ELISA; and measurement of p24 antigen. Serum immunoglobulins; lympocyte mitogen responses; and CD4+ cell numbers were obrtained in 54 sequential patients. Compared to seronegative subjects meab CD4+ cell numbers were decreased and serum immunoglobulins; particularly IgM and IgG; were increased in all groups of seropositive subjects. [abstract terminated]

Genital ulcers and transmission of HIV among couples in Zimbabwe.

Seventy-five married men found to be positive for HIV-1 in Harare, Zimbabwe, were interviewed in order to define behaviours associated with acquisition of infection and to determine factors associated with transmission of infection to their wives. The majority of infected men reported sexual intercourse with multiple heterosexual partners and female prostitutes, and gave a history of sexually transmitted diseases (STDs). All subjects denied homosexual activity and parenteral drug abuse. Serological testing of the wives of seropositive men showed that 45 (60%) were HIV-antibody-positive. Wives of men with AIDS and AIDS-related complex (ARC) and wives of men who gave a history of genital ulcer disease were more likely to be seropositive. The study demonstrates that HIV-1 infection in Zimbabwe occurs through heterosexual intercourse and is associated with other STDs. In addition, the study shows that male to female transmission of HIV-1 is facilitated by the presence of genital ulcers in infected men.

PIP: As part of a prospective cohort study of Zimbabweans seropositive for human immunodeficiency virus (HIV) infection, the factors associated with HIV transmission from husband to wife were analyzed in 75 couples. The mean age of the infected men was 32.1 years; all had been married for at least 1 year and 53 had at least 1 child. None of the men acknowledged a history of homosexual practices or intravenous drug use. All 75 had received injections, but only at reputable health care facilities, and none had been blood transfusion recipients. 4 men (5%) were asymptomatic, 40 (53%) had persistent generalized lymphadenopathy, 24 (32%) had acquired immunodeficiency syndrome (AIDS)-related complex (ARC), and 7 (9%) had full-blown AIDS. Of the 75 wives tested, 45 (60%) were seropositive for HIV-1 infection. Seropositivity was significantly more common among women married to men with ARC (71% infection rate) and AIDS (86% infection rate). Comparison of concordant (both seropositive) and discordant (husband only seropositive) couples indicated no significant differences in terms of age, duration of marriage, number of children, oral contraceptive use by the wife, husband's contact with prostitutes, or sexual activity on the part of the husband with multiple partners in the preceding 3 years. In addition, there was no significant difference between groups in terms of history of sexually transmitted diseases. However, men who reported a history of genital ulcer disease were significantly more likely to have a wife who was seropositive (relative risk, 1.94; 95% confidence interval, 1.62-15.13). This difference persisted even when the male's stage of disease was controlled. Thus, it appears that HIV-1 infected men with genital ulcers are likely to transmit the infection through vaginal intercourse.

Management of gonococcal ophthalmia neonatorum with single-dose kanamycin and ocular irrigation with saline.

Two hundred nineteen neonates with gonococcal ophthalmia neonatorum, including 40 infected with penicillinase-producing strains, were treated as outpatients with a single intramuscular injection of 100 mg of kanamycin and hourly ocular irrigation with saline. Neisseria gonorrhoeae was isolated from three (1.4%) of the 212 babies attending for follow-up, and post-gonococcal conjunctivitis developed in 22 (10.4%) of those who returned for follow-up.

Urethral trichomoniasis in men.

Three hundred twenty-five men with confirmed urethral trichomoniasis were seen at sexually transmitted diseases clinics in Harare, Zimbabwe, in 1983-1984. The mean age of these patients was 30.4 years. The most common symptoms were urethral discharge and urethral irritation. Symptoms in 252 patients (78%) had been present for more than four weeks. Only 1.5% of 5548 patients with nontrichomonal nongonococcal urethritis had had symptoms for this length of time. In most patients with trichomoniasis (99.4%), the discharge was milky white and fluid in nature; when a smear of the discharge was made on a glass slide, small clumps of material were noted. Microscopic examination of the gram-stained smear showed relatively few polymorphonuclear leukocytes but many epithelial cells. Although Trichomonas vaginalis was readily demonstrated by microscopy of both urethral secretions and centrifuged deposits of urine, the organism was cultured only from urethral exudates. Concomitant infection with T. vaginalis was uncommon in patients with proved gonococcal urethritis. Treatment of trichomoniasis in men with a single 2-g dose of metronidazole was unsuccessful in 42.9% of cases. However, treatment with 400 mg of metronidazole thrice daily for five days gave a cure rate of 100%.

The decentralisation of the sexually transmitted diseases service and its integration into primary health care.

PIP: As part of National Health Policy, the City Health Department in Harare, Zimbabwe decentralized sexually transmitted diseases (STD) services and integrated it into primary health care. A central referral STD clinic was created to concentrate expertise. Simplified treatment protocols were distributed to primary care clinics, and nurses in these clinics received an intensive 2-week training course at the central clinic. This was part of a larger plan to provide comprehensive health care in easily accessible settings. The Harare City Health Department has 14 primary care clinics and 9 polyclinics staffed mainly by nursing personnel. The training course taught curative treatment of STDs and prevention by patient education and locating sexual contacts. Participants were expected to be able to utilize physical and laboratory diagnostic techniques accurately to identify common STDs, and to order appropriate treatment. The program emphasized "bedside" teaching with continuous exposure to clinical problems and discussion of those problems. The textbook used included management guidelines in the form of flow charts adapted from World Health Organization guidelines. Over 16 weeks, 49 trainees attended the course. Trainees were mainly female, while patients are mainly male. Trainees performed well, gaining self confidence and ability to manage STDs. The main problems encountered were overwork of staff in clinics when 1 lest for the program, and reluctance of male patients to be examined by female trainees.^ieng

Treatment of infection due to penicillinase-producing Neisseria gonorrhoeae with oral thiamphenicol and with oral lymecycline.

Seventy-five men with gonococcal urethritis were treated with a single oral dose of thiamphenicol, and 88 men with this infection were treated with two 1.5-g oral doses of lymecycline taken 12 hr apart. Of the 75 subjects treated with thiamphenicol, 72 (96%) were cured, as compared with 80 (91%) treated with lymecycline. Sixty subjects (37%) were infected with penicillinase-producing Neisseria gonorrhoeae. In this group, 28 (97%) of 29 subjects treated with thiamphenicol were cured, as compared with 29 (94%) of 31 subjects treated with lymecycline. Patient compliance with the two-dose regimen was excellent, and no adverse effects occurred with either drug. Lymecycline may therefore be an effective alternative to thiamphenicol in those countries where strains of N. gonorrhoeae remain sensitive to the tetracyclines.

Report on AIDS preventions and control activities

The report covers last quarter of 1988 and first quarter of 1989. The main thrust of the short term plan (STP) was on information and education for the general public; training of health workers in various aspects of HIV infection and AIDS; development of the National Public Health Laboratory to have the capacity to test for HIV and the expansion and decentralization os the Blood Transfusion Service