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      Prevalence and risk factors associated with HIV and syphilis co-infection in the African Cohort Study: a cross-sectional study

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          Abstract

          Background

          Each year, 5.6 million new syphilis cases are diagnosed globally. Guidelines for people living with HIV (PLWH) in low-income countries (LIC) recommend STI testing for symptomatic persons and those newly diagnosed with HIV; routine STI testing is less clear. Here we provide updated syphilis prevalence and identify co-infection risk factors in PLWH in the African Cohort Study (AFRICOS) to understand these rates as they relate to syndromic treatment.

          Methods

          AFRICOS is a study enrolling PLWH and HIV-uninfected individuals in four African countries. Participant study enrollment information was used to determine syphilis prevalence and co-infection risk factors. Inclusion criteria consisted of adults 18 years or older receiving care at a participating clinic as a long-term resident who consented to data and specimen collection. Exclusion criteria consisted of pregnancy and/or imprisonment. Screen-positive syphilis was defined as a reactive rapid plasma regain (RPR) upon study enrollment whereas confirmed syphilis included a reactive RPR followed by reactive treponemal test. Multivariate analyses was performed to determine HIV and syphilis co-infection risk factors.

          Results

          Between 2013 and March 1, 2020, 2939 PLWH enrolled and 2818 were included for analysis. Screen-positive and confirmed syphilis prevalence were 5.3% (151/2818) and 3.1% (87/2818), respectively. When the analysis was restricted to PLWH with an RPR titer of greater than, or equal to, 1:8, 11/87 (12.6%) participants were included. No PLWH and confirmed syphilis had documented genital ulcers. In the multivariate model, participants with confirmed syphilis co-infection were more likely to have none or some primary education [aOR 3.29 (1.60, 6.74)] and consume alcohol [aOR 1.87 (1.16, 3.03)] compared to those without syphilis. Antiretroviral therapy (ART) with suppressed viral load (VL) was protective in the unadjusted model but not adjusted multivariate model.

          Conclusions

          Our findings show that syphilis rates in sub-Saharan Africa remain elevated where diagnosis remains challenging, and that both lower education level and alcohol consumption are significantly associated with HIV/syphilis co-infection in AFRICOS. Based on our analysis, current STI guidelines targeting testing for African individuals with either new HIV diagnosis or syndromic symptoms may be inadequate, highlighting the need for increased testing and treatment strategies in resource-limited settings.

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          Most cited references10

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          Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting

          Background Quantifying sexually transmitted infection (STI) prevalence and incidence is important for planning interventions and advocating for resources. The World Health Organization (WHO) periodically estimates global and regional prevalence and incidence of four curable STIs: chlamydia, gonorrhoea, trichomoniasis and syphilis. Methods and Findings WHO’s 2012 estimates were based upon literature reviews of prevalence data from 2005 through 2012 among general populations for genitourinary infection with chlamydia, gonorrhoea, and trichomoniasis, and nationally reported data on syphilis seroprevalence among antenatal care attendees. Data were standardized for laboratory test type, geography, age, and high risk subpopulations, and combined using a Bayesian meta-analytic approach. Regional incidence estimates were generated from prevalence estimates by adjusting for average duration of infection. In 2012, among women aged 15–49 years, the estimated global prevalence of chlamydia was 4.2% (95% uncertainty interval (UI): 3.7–4.7%), gonorrhoea 0.8% (0.6–1.0%), trichomoniasis 5.0% (4.0–6.4%), and syphilis 0.5% (0.4–0.6%); among men, estimated chlamydia prevalence was 2.7% (2.0–3.6%), gonorrhoea 0.6% (0.4–0.9%), trichomoniasis 0.6% (0.4–0.8%), and syphilis 0.48% (0.3–0.7%). These figures correspond to an estimated 131 million new cases of chlamydia (100–166 million), 78 million of gonorrhoea (53–110 million), 143 million of trichomoniasis (98–202 million), and 6 million of syphilis (4–8 million). Prevalence and incidence estimates varied by region and sex. Conclusions Estimates of the global prevalence and incidence of chlamydia, gonorrhoea, trichomoniasis, and syphilis in adult women and men remain high, with nearly one million new infections with curable STI each day. The estimates highlight the urgent need for the public health community to ensure that well-recognized effective interventions for STI prevention, screening, diagnosis, and treatment are made more widely available. Improved estimation methods are needed to allow use of more varied data and generation of estimates at the national level.
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            Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention.

            Sexually transmitted co-infections increase HIV infectiousness through local inflammatory processes. The prevalence of STI among people living with HIV/AIDS has implications for containing the spread of HIV in general and the effectiveness of HIV treatments for prevention in particular. Here we report a systematic review of STI co-infections in people living with HIV/AIDS. We focus on STI contracted after becoming HIV infected. Electronic database and manual searches located 37 clinical and epidemiological studies of STI that increase HIV infectiousness. Studies of adults living with HIV/AIDS from developed and developing countries reported STI rates for 46 different samples (33 samples had clinical/laboratory confirmed STI). The overall mean point-prevalence for confirmed STI was 16.3% (SD=16.4), and median 12.4% STI prevalence in people living with HIV/AIDS. The most common STI studied were Syphilis with median 9.5% prevalence, Gonorrhea 9.5%, Chlamydia 5%, and Trichamoniasis 18.8% prevalence. STI prevalence was greatest at the time of HIV diagnosis, reflecting the role of STI in HIV transmission. Prevalence of STI among individuals receiving HIV treatment was not appreciably different from untreated persons. The prevalence of STI in people infected with HIV suggests that STI co-infections could undermine efforts to use HIV treatments for prevention by increasing genital secretion infectiousness.
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              An Update on the Global Epidemiology of Syphilis

              Purpose of Review Syphilis continues to cause morbidity and mortality worldwide. While syphilis infection is easily identifiable and treatable, rates of syphilis infection continue to increase among select populations in high-income countries and remain at endemic levels in low- and middle-income counties. Recent findings World Health Organization recommended strategies have led to the dual elimination of mother-to-child transmission of syphilis and HIV in several countries, however outbreaks among select populations need to be adequately addressed. Summary Continued vigilance and investment is needed to address syphilis worldwide. The epidemiology of syphilis differs in high-income and low- and middle-income counties.
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                Author and article information

                Contributors
                laura.j.gilbert.mil@mail.mil
                Journal
                BMC Infect Dis
                BMC Infect Dis
                BMC Infectious Diseases
                BioMed Central (London )
                1471-2334
                30 October 2021
                30 October 2021
                2021
                : 21
                : 1123
                Affiliations
                [1 ]GRID grid.507680.c, ISNI 0000 0001 2230 3166, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, ; Silver Spring, MD USA
                [2 ]GRID grid.201075.1, ISNI 0000 0004 0614 9826, Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., ; Bethesda, MD USA
                [3 ]HJF Medical Research International, Abuja, Nigeria
                [4 ]HJF Medical Research International, Mbeya, Tanzania
                [5 ]GRID grid.452639.f, Makerere University-Walter Reed Project, ; Kampala, Uganda
                [6 ]U.S. Army Medical Research Directorate – Africa, Kisumu, Kenya
                [7 ]HJF Medical Research International, Kisumu, Kenya
                [8 ]HJF Medical Research International, Kericho, Kenya
                Article
                6668
                10.1186/s12879-021-06668-6
                8557019
                34717564
                1012243a-2671-47fd-a656-b1eaaa654a01
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 21 June 2021
                : 30 August 2021
                Funding
                Funded by: President's Emergency Plan for AIDS Relief
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award ID: W81XWH-11-2-0174, W81XWH-18-2-0040
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2021

                Infectious disease & Microbiology
                human immunodeficiency virus (hiv),syphilis,africa
                Infectious disease & Microbiology
                human immunodeficiency virus (hiv), syphilis, africa

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