Johnson LF, Coetzee DJ, Dorrington RE. Sentinel surveillance of sexually transmitted infections in South Africa: a review

Centre for Actuarial Research, 10 University Avenue, University of Cape Town, Private Bag, Rondebosch 7701, South Africa.
Sexually Transmitted Infections (Impact Factor: 3.4). 09/2005; 81(4):287-93. DOI: 10.1136/sti.2004.013904
Source: PubMed


To review studies of sexually transmitted infection (STI) prevalence in South Africa between 1985 and 2003 in selected sentinel populations. To examine how STI prevalence varies between populations and to identify the limitations of the existing data.
Studies of the prevalence of syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, gonorrhoea, chlamydia, trichomoniasis, bacterial vaginosis, candidiasis, and herpes simplex virus type 2 (HSV-2) were considered. Results were included if they related to women attending antenatal clinics or family planning clinics, commercial sex workers, individuals in the general population (household surveys), patients with STIs, patients with genital ulcer disease (GUD), or men with urethritis.
High STI prevalence rates have been measured, particularly in the case of HSV-2, trichomoniasis, bacterial vaginosis and candidiasis. The aetiological profile of GUD appears to be changing, with more GUD caused by HSV-2 and less caused by chancroid. The prevalence of gonorrhoea and syphilis is highest in "high risk" groups such as sex workers and attenders of STI clinics, but chlamydia and trichomoniasis prevalence levels are not significantly higher in these groups than in women attending antenatal clinics.
The prevalence of STIs in South Africa is high, although there is extensive variability between regions. There is a need for STI prevalence data that are more nationally representative and that can be used to monitor prevalence trends more reliably.

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Available from: David Coetzee
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    • "South Africa (SA) is at the epicenter of the human immunodeficiency virus (HIV) epidemic; and other sexually transmitted infections (STIs) continue to be endemic [1-3]. STIs have been associated with pelvic inflammatory disease, adverse pregnancy outcomes, cervical cancer, infertility, and multiple reproductive tract sequelae [4]. "
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    ABSTRACT: Background and objectivesSexually transmitted infections (STIs) contribute largely to the burden of health in South Africa and are recognized as major contributors to the human immunodeficiency virus (HIV) epidemic. Young women are particularly vulnerable to STIs. The purpose of this secondary analysis was to examine the risk factors associated with prevalent and incident STIs among women who had participated in three clinical trials.MethodsA total of 5,748 women were screened and 2293 sexually active, HIV negative, non-pregnant women were enrolled in three clinical trials in Kwazulu-Natal, South Africa. The prevalence of individual STIs Chlamydia trachomatis (CT), Neisseria gonorrhea (NG), syphilis, and Trichomonas vaginalis (TV) was assessed at screening; and incident infections were evaluated over a 24 month period.ResultsOverall, the combined study population of all three trials had a median age of 28 years (inter-quartile range (IQR):22–37), and a median duration of follow-up of 12 months. Prevalence of STIs (CT, NG, TV, or syphilis) was 13% at screening. The STI incidence was estimated to be 20/100 women years. Younger women (<25 years, p < 0.001), women who were unmarried (p < 0.001) and non-cohabiting women (p < 0.001) were shown to be at highest risk for incident STIs.ConclusionsThese results confirm the extremely high prevalence and incidence of STIs among women living in rural and urban communities of KwaZulu-Natal, South Africa, where the HIV epidemic is also particularly severe. These findings strongly suggest an urgent need to allocate resources for STI and HIV prevention that mainly target younger women.Trial registrationClinical, NCT00121459.
    Full-text · Article · Sep 2014 · AIDS Research and Therapy
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    • "Nevertheless, STIs are highly prevalent in developing countries. Prevalence of STIs in South Africa has been reported to be between 20–40% for candidiasis and bacterial vaginosis, 10%–42% for syphilis and 5–31% for gonorrhoea [27], compared to our self-reported prevalence of just over 50% in the past three months for signs, symptoms, diagnosis or treatment of any STI. However, while STIs were poorly measured in the current study, this factor still emerged as being highly associated with pregnancy risk. "
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    ABSTRACT: Women in HIV prevention trials often must typically agree to avoid pregnancy. Regardless, some become pregnant. Screening tools predicting pregnancy risk could maximize trial safety and efficiency. We assessed incidence and correlates of pregnancy among women at high HIV risk. We enrolled sexually-active, HIV-negative women into an observational cohort (2008-2011). At enrolment demographic, contraceptive, reproductive, pregnancy intention and behavioural data were collected. Women reported if one or both partners wanted or intended for the couple to become pregnant. We measured gender role beliefs using a locally validated eight-point index. We tested HIV and pregnancy, and inquired about sexually transmitted infection symptoms (STIs) at enrollment and monthly. HIV testing included behavioural counselling and condom provision, but did not specifically counsel women to avoid pregnancy. Cox proportional hazard modelling evaluated the associations with pregnancy. The multivariate model included the following variables "Recent pregnancy attempts", "Gender Roles Beliefs", "Self-reported STIs" and "Age". We screened 1068 women and excluded (24.6%, 263/1068) who did not report risk behaviour. Non-pregnant, non-sterilized women aged 18-35 (median = 21 years) enrolled (n = 438). Most women reported one partner (74.7%) and a prior live birth (84.6%). Median follow-up time was 6 months (range 0.7-15.5). Pregnancy incidence was 25.1 per 100 women-years (n = 57 pregnancies). Conservative beliefs on gender roles (Adjusted Hazard Ratio (aHR) 1.8; 95% confidence interval [CI] 1.1-2.9), recent pregnancy attempts (aHR 1.9; 95% CI 1.1-3.4) and baseline self-reported STI (aHR 2.5; 95% CI 1.4-4.4) were associated with increased incident pregnancy. Report of no pregnancy intention was associated with lowered pregnancy risk (aHR 0.3; 95% CI 0.1-0.7). We identified new and confirmed existing factors that can facilitate screening for pregnancy risk.
    Full-text · Article · May 2014 · PLoS ONE
    • "The model was fitted to HIV data from three national surveys, using disaggregated male and female prevalence values when available (for 2002, 2005) and a combined prevalence for 2008 (five HIV prevalence data points in total for the general population) [11,12,26]; and also to HIV prevalence data among female sex workers (FSWs) (1997) and their clients (2000). Additionally, the model was fitted to syphilis and gonorrhoea/chlamydia prevalence data from FSWs (1997) [13,27]. HSV-2 data from the CAPRISA trial [5], adjusting for HIV status [11], was used as a proxy for the general population HSV-2 prevalence. "
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    ABSTRACT: There is urgent need for effective HIV prevention methods that women can initiate. The CAPRISA 004 trial showed that a tenofovir-based vaginal microbicide had significant impact on HIV incidence among women. This study uses the trial findings to estimate the population-level impact of the gel on HIV and HSV-2 transmission, and price thresholds at which widespread product introduction would be as cost-effective as male circumcision in urban South Africa. The estimated 'per sex-act' HIV and HSV-2 efficacies were imputed from CAPRISA 004. A dynamic HIV/STI transmission model, parameterised and fitted to Gauteng (HIV prevalence of 16.9% in 2008), South Africa, was used to estimate the impact of gel use over 15 years. Uptake was assumed to increase linearly to 30% over 10 years, with gel use in 72% of sex-acts. Full economic programme and averted HIV treatment costs were modelled. Cost per DALY averted is estimated and a microbicide price that equalises its cost-effectiveness to that of male circumcision is estimated. Using plausible assumptions about product introduction, we predict that tenofovir gel use could lead to a 12.5% and 4.9% reduction in HIV and HSV-2 incidence respectively, by year 15. Microbicide introduction is predicted to be highly cost-effective (under $300 per DALY averted), though the dose price would need to be just $0.12 to be equally cost-effective as male circumcision. A single dose or highly effective (83% HIV efficacy per sex-act) regimen would allow for more realistic threshold prices ($0.25 and $0.33 per dose, respectively). These findings show that an effective coitally-dependent microbicide could reduce HIV incidence by 12.5% in this setting, if current condom use is maintained. For microbicides to be in the range of the most cost-effective HIV prevention interventions, product costs will need to decrease substantially.
    No preview · Article · Jan 2014 · BMC Infectious Diseases
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