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      Acceptability and Feasibility of Integrating Point-of-Care Diagnostic Testing of Sexually Transmitted Infections into a South African Antenatal Care Program for HIV-Infected Pregnant Women

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          Abstract

          Background

          Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) infections may increase the risk of vertical transmission of the human immunodeficiency virus (HIV). In resource-limited settings, symptomatic screening, and syndromic management of sexually transmitted infections (STIs) during pregnancy continue to be the standard of care. In the absence of diagnostic testing, asymptomatic infections in pregnant women go untreated.

          Objective

          To describe the acceptability and feasibility of integrating diagnostic STI screening into first antenatal care visits for HIV-infected pregnant women.

          Methods

          HIV-infected pregnant women were recruited during their first antenatal care visit from three antenatal care clinics in Tshwane District, South Africa, between June 2016 and October 2017. Self-collected vaginal swabs were used to screen for CT, NG, and TV with a diagnostic point-of-care (POC) nucleic acid amplification test. Those with STIs were provided treatment per South African national guidelines.

          Results

          Of 442 eligible women, 430 (97.3%) agreed to participate and were tested. Of those with a positive STI test result ( n = 173; 40.2%), 159 (91.9%) received same-day results and treatment; 100% of STI-infected women were treated within seven days.

          Conclusions

          Integration of POC diagnostic STI screening into first-visit antenatal care services was feasible and highly acceptable for HIV-infected pregnant women.

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          Most cited references13

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          Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries.

          M Beksinska, John D Watson, Mohammad Mullick … (2005)
          Sexually transmitted infections (STIs) are common in the developing world. Management of STIs in pregnancy in many developing countries has, however, been complicated by the lack of simple and affordable diagnostic tests. This review examines the prevalence and impact on pregnancy outcome of STIs in developing countries and recommends approaches to management of STIs in pregnancy for resource poor settings.
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            The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and meta-analysis.

            Timothy Johnson, Paul Lewis (2008)
            This article reviews the effect of genital tract infections and associated clinical conditions on the detection and concentration of HIV-1 shedding in the genital tract. A search of the PubMed, Embase, and AIDSearch databases was conducted. Meta-analysis was performed on those studies that reported the effect of genital tract infections on the detection of HIV-1 shedding. Thirty-nine studies met the inclusion criteria. The odds of HIV-1 detection in the genital tract were increased most substantially by urethritis (OR 3.1, 95% CI: 1.1-8.6) and cervicitis (OR 2.7, 95% CI: 1.4-5.2). The odds of HIV-1 detection were also increased significantly in the presence of cervical discharge or mucopus (OR 1.8, 95% CI: 1.2-2.7), gonorrhoea (OR 1.8, 95% CI: 1.2-2.7), chlamydial infection (OR 1.8, 95% CI: 1.1-3.1), and vulvovaginal candidiasis (OR 1.8, 95% CI: 1.3-2.4). Other infections and clinical conditions were found to have no significant effect on the detection of HIV-1, although HSV-2 shedding was found to increase the concentration of HIV-1 shedding, and genital ulcer disease was found to increase the odds of HIV-1 detection significantly after excluding one biased study (OR 2.4, 95% CI: 1.2-4.9). This analysis shows that infections that are associated with significant increases in leukocyte concentrations in the genital tract are also associated with significant increases in HIV-1 shedding. These infections are likely to be particularly important in promoting the sexual transmission and mother-to-child intrapartum transmission of HIV-1, and should therefore be the focus of HIV prevention strategies.
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              Trichomonas vaginalis as a cause of perinatal morbidity: a systematic review and meta-analysis.

              Bronwyn Silver, Rebecca J. Guy, John Kaldor … (2014)
              Trichomonas vaginalis is the most common curable sexually transmissible infection worldwide, with high rates in women of reproductive age. There have been inconsistent findings about the impact of infection and its treatment in pregnancy. We conducted a meta-analysis to determine the association between T. vaginalis and perinatal outcomes. Electronic databases were searched to May 2013. Included studies reported perinatal outcomes in women infected and uninfected with T. vaginalis. Meta-analysis calculated a pooled relative risk (RR) and 95% confidence interval (CI) using either a fixed- or random-effects model. Study bias was assessed using funnel plots. Of 178 articles identified, 11 studies met the inclusion criteria. The study populations, outcomes, and quality varied. T. vaginalis in pregnancy was associated with an increased risk of preterm birth (RR, 1.42; 95% CI, 1.15-1.75; 9 studies; n = 81,101; I = 62.7%), preterm premature rupture of membranes (RR, 1.41; 95% CI,1.10-1.82; 2 studies; n = 14,843; I = 0.0%) and small for gestational age infants (RR, 1.51; 95% CI,1.32-1.73; 2 studies; n = 14,843; I = 0.0%). Sensitivity analyses of studies that accounted for coinfection with other sexually transmissible infection found a slightly reduced RR of 1.34 for preterm birth (95% CI, 1.19-1.51; 6 studies; n = 72,077; I = 11.2%), and in studies where no treatment was confirmed, the RR was 1.83 (95% CI, 0.98-3.41; 3 studies; n = 1795; I = 22.3%). Our review provides strong evidence that T. vaginalis in pregnancy is associated with an increased risk of preterm birth. Based on fewer studies, there were also substantial increases in the risk of preterm premature rupture of membranes and small for gestational age infants. Further studies that address the current gaps in evidence on treatment effects in pregnancy are needed.
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                Author and article information

                Contributors
                E. Morikawa:
                ORCID: http://orcid.org/0000-0001-8582-9018
                Journal
                Journal ID (nlm-ta): Infect Dis Obstet Gynecol
                Journal ID (iso-abbrev): Infect Dis Obstet Gynecol
                Journal ID (publisher-id): IDOG
                Title: Infectious Diseases in Obstetrics and Gynecology
                Publisher: Hindawi
                ISSN (Print): 1064-7449
                ISSN (Electronic): 1098-0997
                Publication date Collection: 2018
                Publication date (Electronic): 9 May 2018
                Volume: 2018
                Electronic Location Identifier: 3946862
                Affiliations
                1Division of Infectious Disease, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
                2Research Unit, Foundation for Professional Development, Pretoria, South Africa
                3Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
                4Department of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
                5Anova Health Institute, Johannesburg, South Africa
                6School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
                7Department of Medical Microbiology, School of Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
                8Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
                Author notes

                Academic Editor: Bryan Larsen

                Author information
                http://orcid.org/0000-0001-8582-9018
                http://orcid.org/0000-0002-6922-7364
                Article
                DOI: 10.1155/2018/3946862
                PMC ID: 5971359
                PubMed ID: 29861622
                SO-VID: fd96252e-1f4f-43ec-9511-3493d05d71c3
                Copyright © Copyright © 2018 E. Morikawa et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 23 October 2017
                Date revision received : 10 March 2018
                Date accepted : 29 March 2018
                Funding
                Funded by: David Geffen School of Medicine's Dean's Office
                Funded by: University of California, Los Angeles
                Categories
                Subject: Research Article

                ScienceOpen disciplines: Obstetrics & Gynecology
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology

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