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      The prevalence and incidence of active syphilis in women in Morocco, 1995-2016: Model-based estimation and implications for STI surveillance

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          Abstract

          Background

          Evolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation. We applied the Spectrum STI estimation tool to estimate the prevalence and incidence of active syphilis in adult women in Morocco over 1995 to 2016. The results from the analysis are being used to inform Morocco’s national HIV/STI strategy, target setting and program evaluation.

          Methods

          Syphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics, women attending family planning clinics and other general adult populations, as available post-1995. Prevalence data were adjusted for diagnostic test performance, and for the contribution of higher-risk populations not sampled in surveys. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis.

          Results

          In 2016, active syphilis prevalence was estimated to be 0.56% in women 15 to 49 years of age (95% confidence interval, CI: 0.3%-1.0%), and around 21,675 (10,612–37,198) new syphilis infections have occurred. The analysis shows a steady decline in prevalence from 1995, when the prevalence was estimated to be 1.8% (1.0–3.5%). The decline was consistent with decreasing prevalences observed in TB patients, fishermen and prisoners followed over 2000–2012 through sentinel surveillance, and with a decline since 2003 in national HIV incidence estimated earlier through independent modelling.

          Conclusions

          Periodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. This first-ever undertaking engaged and focused national stakeholders, and confirmed the still considerable syphilis burden. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012. From 2017 Morocco plans to implement a system to record data from routine antenatal programmatic screening, which should help update and re-calibrate next trend estimations.

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          Most cited references9

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          Global prevalence and incidence estimates of selected curable STDs.

          To update the WHO global and regional estimates of the prevalence and incidence of syphilis, gonorrhoea, chlamydia, and trichomoniasis. Prevalence estimates for syphilis, gonorrhoea, chlamydia, and trichomoniasis were generated for each of the nine UN regions for males and females between the ages of 15 and 49 in 1995 based on an extensive review of the published and unpublished medical literature since 1985. Incidence estimates were based on the prevalence figures and adjusted to take into account the estimated average duration of infection for each disease in a particular region. The latter was assumed to depend upon a number of factors including the duration of infection in the absence of treatment, the proportion of individuals who develop symptoms, the proportion of individuals treated, and the appropriateness of treatment. In 1995 there were over 333 million cases of the four major curable STDs in adults between the ages of 15 and 49--12 million cases of syphilis, 62 million cases of gonorrhoea, 89 million cases of chlamydia, and 170 million cases of trichomoniasis. Geographically, the vast majority of these cases were in the developing world reflecting the global population distribution. STDs are among the most common causes of illness in the world. Estimates of the global prevalence and incidence of these infections are limited by quantity and quality of data available from the different regions of the world. Improving global STD estimates will require more well designed epidemiological studies on the prevalence and duration of infection.
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            The distribution of new HIV infections by mode of exposure in Morocco

            Objectives Building on a wealth of new empirical data, the objective of this study was to estimate the distribution of new HIV infections in Morocco by mode of exposure using the modes of transmission (MoT) mathematical model. Methods The MoT model was implemented within a collaboration with the Morocco Ministry of Health and the Joint United Nations Programme on HIV/AIDS. The model was parameterised through a comprehensive review and synthesis of HIV and risk behaviour data in Morocco, mainly through the Middle East and North Africa HIV/AIDS Synthesis Project. Uncertainty analyses were used to assess the reliability of and uncertainty around our calculated estimates. Results Female sex workers (FSWs), clients of FSWs, men who have sex with men (MSM) and injecting drug users (IDUs) contributed 14%, 24%, 14% and 7% of new HIV infections, respectively. Two-thirds (67%) of new HIV infections occurred among FSWs, clients of FSWs, MSM and IDUs, or among the stable sexual partners of these populations. Casual heterosexual sex contributed 7% of HIV infections. More than half (52%) of HIV incidence is among females, but 71% of these infections are due to an infected spouse. The vast majority of HIV infections among men (89%) are due to high-risk behaviour. A very small HIV incidence is predicted to arise from medical injections or blood transfusions (0.1%). Conclusions The HIV epidemic in Morocco is driven by HIV incidence in high-risk population groups, with commercial heterosexual sex being the largest contributor to incidence. There is a need to focus HIV response more on these populations, mainly through proactive and sustainable HIV surveillance, and the expansion and increased geographical coverage of services such as condom promotion among FSWs, voluntary counselling and testing, harm reduction and treatment.
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              Improving global estimates of syphilis in pregnancy by diagnostic test type: A systematic review and meta-analysis

              Background “Probable active syphilis,” is defined as seroreactivity in both non-treponemal and treponemal tests. A correction factor of 65%, namely the proportion of pregnant women reactive in one syphilis test type that were likely reactive in the second, was applied to reported syphilis seropositivity data reported to WHO for global estimates of syphilis during pregnancy. Objectives To identify more accurate correction factors based on test type reported. Search Strategy Medline search using: “Syphilis [Mesh] and Pregnancy [Mesh],” “Syphilis [Mesh] and Prenatal Diagnosis [Mesh],” and “Syphilis [Mesh] and Antenatal [Keyword]. Selection Criteria Eligible studies must have reported results for pregnant or puerperal women for both non-treponemal and treponemal serology. Data collection and analysis We manually calculated the crude percent estimates of subjects with both reactive treponemal and reactive non-treponemal tests among subjects with reactive treponemal and among subjects with reactive non-treponemal tests. We summarized the percent estimates using random effects models. Main results Countries reporting both reactive non-treponemal and reactive treponemal testing required no correction factor. Countries reporting non-treponemal testing or treponemal testing alone required a correction factor of 52.2% and 53.6%, respectively. Countries not reporting test type required a correction factor of 68.6%. Conclusions Future estimates should adjust reported maternal syphilis seropositivity by test type to ensure accuracy.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                24 August 2017
                2017
                : 12
                : 8
                : e0181498
                Affiliations
                [1 ] Ministry of Health, Directorate of Epidemiology and Disease Control, Rabat, Morocco
                [2 ] STIs Laboratory, Department of Bacteriology, National Institute of Hygiene, Rabat, Morocco
                [3 ] UNAIDS Morocco country office, Rabat, Morocco
                [4 ] London, United Kingdom
                [5 ] Weill Cornell Medical College - Qatar, Cornell University, Doha, Qatar
                [6 ] World Health Organization, Dept. of Reproductive Health and Research, Geneva, Switzerland
                [7 ] Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, Georgia, United States of America
                [8 ] Avenir Health, Glastonbury, Connecticut, United States of America
                Columbia University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: EK JS.

                • Data curation: AB AEK AH HER KA LAR AS MT MY.

                • Formal analysis: EK GM LAR JR.

                • Funding acquisition: EK JS LAR.

                • Methodology: EK GM LAR JR JS.

                • Project administration: MT AB.

                • Software: GM JS.

                • Supervision: MT MY.

                • Validation: JS JR.

                • Visualization: EK LAR JR.

                • Writing – original draft: EK.

                • Writing – review & editing: JR LAR AEK AB.

                Author information
                http://orcid.org/0000-0002-5301-8461
                Article
                PONE-D-17-01131
                10.1371/journal.pone.0181498
                5570350
                28837558
                1777c3b4-a03e-4daa-83d4-dd30f8afb072
                © 2017 Bennani et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 10 January 2017
                : 3 July 2017
                Page count
                Figures: 4, Tables: 2, Pages: 15
                Funding
                Funded by: World Health Organization, Dept. of Reproductive Health and Research
                Award ID: XXX
                Award Recipient :
                Funded by: Qatar National Research Fund (QA)
                Award ID: NPRP 9-040-3-008
                Award Recipient :
                The project was funded by the World Health Organization, Department of Reproductive Health and Research, STI program. LAR and AS acknowledge the support of Qatar National Research Fund (NPRP 9-040-3-008) that provided funding for collating data and analyses provided to this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                Medicine and Health Sciences
                Urology
                Genitourinary Infections
                Syphilis
                Medicine and Health Sciences
                Infectious Diseases
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                Syphilis
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                Infectious Diseases
                Bacterial Diseases
                Treponematoses
                Syphilis
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