Etiologies of genital inflammation and ulceration in symptomatic Rwandan men and women responding to radio promotions of free screening and treatment services

Abstract

Introduction The longstanding inadequacies of syndromic management for genital ulceration and inflammation are well-described. The Rwanda National Guidelines for sexually transmitted infection (STI) syndromic management are not yet informed by the local prevalence and correlates of STI etiologies, a component World Health Organization guidelines stress as critical to optimize locally relevant algorithms. Methods Radio announcements and pharmacists recruited symptomatic patients to seek free STI services in Kigali. Clients who sought services were asked to refer sexual partners and symptomatic friends. Demographic, behavioral risk factor, medical history, and symptom data were collected. Genital exams were performed by trained research nurses and physicians. We conducted phlebotomy for rapid HIV and rapid plasma reagin (RPR) serologies and vaginal pool swab for microscopy of wet preparation to diagnose Trichomonas vaginalis (TV), bacterial vaginosis (BV), and vaginal Candida albicans (VCA). GeneXpert testing for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were conducted. Here we assess factors associated with diagnosis of NG and CT in men and women. We also explore factors associated with TV, BV and VCA in women. Finally, we describe genital ulcer and RPR results by HIV status, gender, and circumcision in men. Results Among 974 men (with 1013 visits), 20% were positive for CT and 74% were positive for NG. Among 569 women (with 579 visits), 17% were positive for CT and 27% were positive for NG. In multivariate analyses, factors associated with CT in men included younger age, responding to radio advertisements, <17 days since suspected exposure, and not having dysuria. Factors associated with NG in men included not having higher education or full-time employment, <17 days since suspected exposure, not reporting a genital ulcer, and having urethral discharge on physical exam. Factors associated with CT in women included younger age and < = 10 days with symptoms. Factors associated with NG in women included younger age, lower education and lack of full-time employment, sometimes using condoms vs. never, using hormonal vs. non-hormonal contraception, not having genital ulcer or itching, having symptoms < = 10 days, HIV+ status, having BV, endocervical discharge noted on speculum exam, and negative vaginal wet mount for VCA. In multivariate analyses, only reporting >1 partner was associated with BV; being single and RPR+ was associated with TV; and having < = 1 partner in the last month, being pregnant, genital itching, discharge, and being HIV and RPR negative were associated with VCA. Genital ulcers and positive RPR were associated with being HIV+ and lack of circumcision among men. HIV+ women were more likely to be RPR+. In HIV+ men and women, ulcers were more likely to be herpetic rather than syphilitic compared with their HIV- counterparts. Conclusions Syndromic management guidelines in Rwanda can be improved with consideration of the prevalence of confirmed infections from this study of symptomatic men and women representative of those who would seek care at government health centers. Inclusion of demographic and risk factor measures shown to be predictive of STI and non-STI dysbioses may also increase diagnostic accuracy.

Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable

“…The combination of genital inflammation and higher HIV viremia significantly increases the risk for HIV transmission. 52 Findings from the current study add to the growing body of research on HIV disclosure to sex partners in the era of U=U. Similar to past research, we found that disclosing one's HIV status clustered with disclosure across multiple relationships.…”

“…The combination of genital inflammation and higher HIV viremia significantly increases the risk for HIV transmission. 52…”

Prospective Cohort Study of Treatment Outcomes of Vaginal Discharge Syndrome in Women in Windhoek, Namibia

“…As expected, C. albicans was the most common species, but 27% of women with VVC had non– albicans Candida species, especially C. glabrata , C. tropicalis , and C. krusei. 15–19 Interestingly, 24% of C. albicans and 80% of non– albicans Candida strains showed in vitro resistance to the first-line drug, fluconazole. These rates of antifungal resistance are in line with reports from other parts of the world, such as Cameroon and Uganda, as well as a previous report that included a different cohort from Namibia 20–22 .…”

Importance of Candida infection and fluconazole resistance in women with vaginal discharge syndrome in Namibia

“…Candida species were detected in 110 (43%) of swabs collected from women with VDS in our study making it the most common microbial aetiology. Studies from sub-Saharan Africa reported a wide range of Candida prevalence in women with VDS: 21% in Rwanda [ 29 ], 25% in Ethiopia [ 30 ], 26% in Mauritania [ 31 ], 29% in Senegal and Gabon [ 15 , 32 ], 38% in Cameroon [ 33 ], 39% in Benin [ 34 ], 45% in South Africa [ 35 ], 49% Burkina Faso [ 36 ], 55% in Nigeria [ 37 ] and 66% in Tanzania [ 38 ]. The geographic differences in the reported prevalence described in different settings might be owing to environmental, behavioural, socioeconomic factors, as well differences in study methodologies [ 30 ].…”