<font size="2" face="Georgia, Arial" color="Black"> HIGH PREVALENCE OF TRICHOMONAS VAGINALIS AMONG HIV-INFECTED WOMEN ATTENDING HEALTH SERVICES IN LUSAKA, ZAMBIA. </font> <font size="2" face="Georgia, Arial" color="Red"> [Original Research] </font><br /> <font size="2" face="Georgia, Arial" color="blue"> Katakwe Alex BSc1, Yassa Pierre, PhD1/2, Hira Rajiv, MBBS3, Sarenje Kelvin, BSc2, Kantenga MS,MD2, Kaswa J, MD4,Ikembo Janine, BPH5 and Hira Subhash, MD,MPH6 </font><br /> <font size="1" face="Georgia, Arial" color="blue"> 1. University Teaching Hospital (UTH), Department of Dermatology and STIs, Lusaka, Zambia. <br />2.University of Zambia School of Medicine, Dept Biomedical Sciences, Lusaka, Zambia. <br /> 3. Emory University, Rollins School of Public Health, Atlanta, USA.<br /> 4. University of Kinshasa, Congo.<br/> 5.University of East London,UK. <br/> 6. MGM University of Health Sciences, Navi Mumbai, India. </font> <br /> <font size="2" face="Georgia, Arial" color="Black"> [emedpub – International Infectious Diseases: Vol 1:10] [Date of Publication: 07.08.2013] </font> <br /> <font size="3" face="Georgia, Arial" color="Black"> ISSN 2231-6019 </font> </p>

July 8, 2013 at 12:29 AM

Abstract:

Objective. The prevalence of co-infections of Trichomonas vaginalis (TV) and HIV in women seeking health services in Lusaka, Zambia was determined in order to quantify the prevalence of T.vaginalis in HIV-infected and HIV-negative women, and identify their risk factors.

Methods. A cross-sectional, laboratory based study of women from socially marginalised communities in four peri-urban clinics and one referral hospital in Lusaka was conducted. HIV status was determined as per HIV test protocol after Voluntary Counselling and Testing. Immunological procedure for Rapid TV Test Kit (Device/Cassette) was used to detect the host’s antibodies against T.vaginalis soon after taking self-administered high vaginal swabs. Parasitological procedure was also done using high vaginal swabs and urine for wet mount microscopy.

Results. Among 472 women enrolled, 49.8% were HIV-infected. The prevalence of T.vaginalis in HIV-infected women was 65.5% as compared with 22.8% among HIV-negative women (p< 0.05). A total of 208/472 (44.1%) of women had Trichomonas vaginalis infection. However, yield of T.vaginalis by wet microscopy method was scanty 10%, possibly due to laboratory limitations. There was lack of culture and PCR facilities.

Conclusions. Significantly high prevalence of T. vaginalis was found in HIV positive women in this study. Trichomonad infection was associated with multiple sexual partners, unmarried status, low education level, suburb residency (compound-life), and unemployment. Prompt syndromic management is recommended for all women with vaginal discharges so as to improve their sexual health and reduce transmission of HIV.

Introduction:

Trichomonas vaginalis (TV) is an anaerobic flagellated protozoan, the most common nonviral and only sexually transmitted parasite and the etiological agent of trichomoniasis [1]. T. vaginalis infection is known to associate with the transmission of human immunodeficiency virus (HIV) and may lead to adverse outcomes in pregnant women. Co-infections of trichomoniasis and HIV have important medical, social, and economical implications. Women who are infected during pregnancy are predisposed to premature rupture of the placental membranes, premature labour, and low-birth-weight infants [2]. Also linked to this disease are intrauterine infection and cervical cancer, atypical pelvic inflammatory disease (PID), and infertility. WHO, estimates that 180 million cases of infection are acquired annually worldwide [3]. Hallmark features of T. vaginalis are the adherence factors that allow cervicovaginal epithelium colonization in women. The pathology induced by T. vaginalis increase HIV shedding.

The purpose this study was to determine the prevalence of co-infections of T. vaginalis and HIV in women seeking health services in Lusaka, Zambia using the New Rapid TV Antigen Test.

Methods:

We conducted a cross-sectional, laboratory based study of women from socially marginalised communities in four peri-urban clinics and one referral health institution. HIV status was determined as per HIV test protocol after Voluntary Counselling and Testing. Immunological procedure for TV Rapid Test Kit (Device/Cassette) JD Biotech with high sensitivity and specificity of 99% and 100% respectively was used to detect the host’s antibodies against T.vaginalis soon after the specimen was taken with self-administered high vaginal swab. The swabs were later eluted in normal saline for wet mount preparation for microscopy. Parasitological procedures were used to analyse urine samples to compare the sensitivity of the new TV Rapid Test with microscopy. Qualitative data was collected through structured interviews with physicians and laboratory technologists to determine whether there were any prevalence survey programmes that recovered T.vaginalis and also review records on prevalence of T.vaginalis cases from microscopy and other methods used in the laboratory.

2.1. Study Design and Participant Enrolment

This was a cross sectional study using mixed qualitative and quantitative methods conducted between August 2012 and February 2013. Purposive sample was recruited from the referral University Teaching Hospital (UTH) at the following sites: STI clinic, gynaecology and antenatal department, medical wards, and CIDRZ centre of excellence. Other study sites included Kalingalinga, Mtendere, George compound and Chilenje clinics. These clinics were purposively sampled as they carter for the high density population and low socio-economic communities. Participants recruited in this study were women aged 18-49 presenting with vaginitis or Non-Specific Urethritis (NSU) or non-Gonococcal vaginitis or gynaecological or urological conditions. Their HIV status was determined after consent and willingness to have an HIV test.

2.2. Sample size

The sample size was calculated based on the Pocock’s formula using assumption of HIV prevalence of 20%  among adult women attending health services in Lusaka. (Fabian, 2009). Taking 80% power and significance level of 0.05, sample required was 128 HIV positive women and 128 HIV negative women; therefore, an initial total of 256 women were recruited. However, to increase the statistical power to 90%, more women were recruited to give an overall total of 472 women.

2.3. Laboratory Methods for Trichomonas vaginalis Detection

HIV status was determined as per HIV test protocol after Voluntary Counselling and Testing. A lancet was used to bleed the ring finger and collect a small sample of blood with a capillary tube. The blood sample was then put on an HIV-1 Determine test strip for immunological procedure. The results were read within 15 minutes and if the initial reading was positive, a Unigold confirmatory test was done. The subjects were then instructed to administer sterile swab and collect urine specimens. Immunological test was done to detect the host’s antibodies against T.vaginalis using the Rapid TV Test Kit of JD Biotech ( Jei Daniel (JD) Biotech Corp, from Jinan, Shandong, China) with high sensitivity and specificity of 99% and 100% respectively. Parasitological procedures were used to analyse urine samples and self-administered high vaginal swabs eluted in normal saline to compare the sensitivity of the new Rapid TV Test with microscopy. HIV test was performed using ELISA test Abbot, Abbot (Clasorin) from Germany.

2.4. Structured interviews with Physicians and Laboratory technologists

Qualitative data was collected through structured interviews with physicians on the general diagnosis, treatment and management of trichomoniasis. Laboratory technologists were interviewed to determine whether there were any prevalence survey programmes that recovered T.vaginalis and casino also review records on prevalence of T.vaginalis cases from microscopy and other methods used in the laboratory (data presented elsewhere).

2.5. Data Analysis

The responses to the open-ended questions from structured interviews with physicians and lab technologists were analysed using the framework method of analysis [4], which is particularly suitable for applied research [5].  As well as providing a structured approach to the identification and coding of themes and sub-themes, the framework method allows for simple descriptive statistical tests (percentages) to be applied as a means to indicating which themes predominated.

Quantitative data from data-collection sheets which included confounding variables such as age, sex, marital status, educational level, occupation and residential place (town, or compound) were categorized and coded. This was entered into the SPSS 16.0 data base. Descriptive statistics were then run using and presented in form of graphs, pie charts and tables. Cross tabulation (contingency) tables were used to establish the association between the independent variable (Trichomonas vaginalis) and the dependent variable (HIV) infection. The Pearson Chi-square test was applied to determine the relationships between T. vaginalis and HIV infections.

2.6. Human Subjects

The study was conducted in accordance with the guidelines of the Ministry of Health on studies involving human subjects. Ethical clearance was sought from UNZA- Research Ethics Committee of School of Medicine. Written authority was obtained from Ministry of Health (MoH). All participants were fully informed of the study objectives, risks involved and their mitigation. After full explanation to the participants in a language they understood, an informed and written consent was obtained from individual participants who either signed the form or used a thumb print depending on their literacy level. All information obtained was kept confidential and limited to care providers, unless the patient wished otherwise.

Results:

Among 472 women with genital symptoms enrolled in the study, the prevalence of T.vaginalis (TV) was 208/472 (44.1%). By comparison, TV was higher in HIV-infected women 154/235 (65.5%) than in HIV-negative women 54/237 (22.8%) (p < 0.05) (table 1).

Table 2 presents the demographic profile of the cohort. The dominant profile of the cohort was: married or cohabitating single women, <30 years of age, having primary or seconday level education, informal or no employment, and living in compound. Almost a quarter of the cohort was pregnant. Interestingly, the dominant profile of HIV TV women was identical to that of the cohort except that dual-infected women were less likely to be pregnant.

Table 3 presents the past history of other STIs among the cohort. Interestingly, almost a quarter of HIV women (with or without TV) had history of syphilis in the recent past.

The New Rapid TV Antigen Test was more sensitive in detecting T. vaginalis than the wet mount microscopy [See Table 4]. Since neither culture nor PCR techniques were available as gold standards to compare the new Rapid TV Antigen test, the level of sensitivity and specificity could not be determined. However, it is evident that the new Rapid TV Antigen test picked up over 90% of the TV infections that were otherwise missed by the wet mount microscopy. Treatment of TV was given using drugs for the management of vaginal discharge under the Syndromic algorithm.

Discussion:

Very few studies have been done to determine the prevalence of co-infections of T. vaginalis and HIV and most have used less sensitive diagnostic test for Trichomonas infection. Significantly high prevalence of T. vaginalis among HIV-infected women (65.5%) as compared with HIV-negative women (22.8%) is suggestive of several synergistic factors responsible for co-infection.

The high prevalence of T. vaginalis was consistent across age groups, marital status, pregnancy status, educational level, employment status, and residence. Similar co-factors were reported for T.vaginalis infection in studies [6,9]. Similarly, risk factors such as being separated, divorced, widowed or single but cohabiting status are associated with high prevalence of T.vaginalis [9].

Significantly high prevalence of T.vaginalis in HIV positive women can be explained in terms of the pathology induced by T. vaginalis infection. The 22.8% HIV-negative women found to have T. vaginalis were at risk of seroconverting to HIV positive if exposed because Trichomonas infection may act to expand the portal of entry for HIV in a negative person [2,3,7,8].

The study had several limitations. Self-administered high vaginal swabs may not have been used properly by some participants. Also, male subjects were excluded during the study design because the self-use of urethral swabs is difficult and swabs from subpreputial space are not a validated method; hence, this study was exclusively for women. Furthermore, low sensitivity of first-catch urine used alongside the high vaginal swabs as specimen could have also impacted negatively on the yield of wet mount preparation and microscopy seen in the study at 10%. The lack of laboratory facilities for culture and/or PCR as gold standard for T.vaginalis is a major weakness of the study.

Conclusions:

We found significantly high prevalence of T. vaginalis in HIV-infected women as compared with HIV-negative women indicating a strong relationship of co-infection of trichomoniasis with HIV. Epidemiologic evidence suggests that all HIV-infected women having vaginal discharge should be provided syndromic treatment so as to improve their sexual health and reduce transmission of HIV.

The new rapid TV test is recommended to be used for the diagnosis, treatment and management of vaginal discharge syndrome in Zambia.

Acknowledgments:

We acknowledge late Head of Biomedical Department UNZA-SOM, Senior lecturer and supervisor Dr Cecilia J. Shinondo for the great academic and moral support provided during the development of this study. Further acknowledgments go to the Authorities at the University of Zambia School of Medicine, MEPH, University Teaching Hospital (UTH), Laboratory Technologists at the Virology, Parasitology, Bacteriology, Skin/STI clinic laboratories at UTH, Sister-in-charge at Mtendere Health Centre Cervical Cancer Department, and all the authorities at Chilenje, George Compound, Mtendere and Kalingalinga Health Centres for the assistance, co-operation and support rendered during the data collection for this study.

References:

  1. Soper D. Trichomoniasis under control or under controlled? Am J Obstet Gynaecol. 2004; 190: 281-90.
  2. Zhang Z.F., Graham S., Yu S.Z., Marshall J. 1995. Trichomonas vaginalis and cervical cancer. A prospective study in China. Ann Epidemiol 1995;5:325-332.
  3. Buvé A., Weiss H. A., Laga M., Van Dyck E., Musonda R., Zekeng L., Kahindo M., Anagonou S., Morison L., Robinson N.J. and Hayes R.J. The epidemiology of trichomoniasis in women in four African cities. Lippincott Williams & Wilkins, Inc, 2010.
  4. Ritchie, J., and Spencer, L. Qualitative data analysis for applied policy research. In:   Analysis Qualitative Data. Ed. A. Bryman and R. Burgess. London: Routlrdge, 1994.
  5. Lathlean, J. Qualitative analysis. In the research process in nursing (5th ed.). Ed. K. Gerrish and A. Lacey. Oxford: Blackwell, 2006.
  6. Sutton M., Sternberg M., Koumans E. H., McQuillan G., Berman S., and Markowitz L. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001–2004. Clin Infect Dis 2007;45:1319–1326.
  7. Sorvillo F.J., Kerndt P., and Ash L. Trichomonas vaginalis:HIV and African-Americans. University of California. Department of Health Services, Los Angeles County, California, 2001.
  8. Helms D., Mosure, D., Metcalf C., Douglas J., Malotte C., Paul S., Peterman T.  Risk   Factors for Prevalent and Incident Trichomonas vaginalis Among Women Attending Three Sexually Transmitted Disease Clinics. Sex Transm Dis 2008;35:484-488.
  9. Bennett C., 1993. The black population in the United States: Current Population Reports.    Washington: US Bureau of Census Publication, 1993. p5.

Table 1:      Prevalence of T. vaginalis among women with HIV status (n=472).

Status HIV( ) (%) HIV(-) (%) Total
TV( ) 154 (65.5) 54 (22.8) 208
TV(-) 81 183 264
Total 235 237 472

Table 2: Demographic profile of women attending health services in Lusaka (n=472).

HIV( ) TV( ) n=154 HIV( ) TV(-) n=81 HIV(-) TV( ) n=54 HIV(-) TV(-) n=183 Total
Age yrs
18- 29 87 42 37 129 295
30 – 39 46 22 16 44 128
40 – 49 21 17 1 10 49
Marital status
Single 0 0 1 0 1
Married 84 50 35 138 307
Divorced 13 9 1 3 26
Separated 3 3 0 0 6
Widowed 8 3 2 1 14
Single but cohabiting 46 16 15 41 118
Education
Nil 6 6 0 2 14
Primary 46 25 21 45 137
Secondary 96 32 49 107 284
Tertiary 6 1 4 26 37
Employment
Formal 21 3 3 28 55
Informal 78 46 19 70 213
Not working 55 32 32 85 204
Residence

Township 15 4 5 16 40
Compound 139 77 49 167 432
Pregnant 15 6 17 62 100

Table 3: Prevalence of T. vaginalis in relation to past history of other STIs (n=472).

History of other STIs HIV( ) TV( ) n=154 HIV( ) TV(-) n=81 HIV(-) TV( ) n=54 HIV(-) TV(-) n=183 Total
Yeast/fungal Infection 3 1 0 6 10
Syphilis 27 18 5 18 68
Gonorrhoea 7 2 3 8 20
Chlamydia 0 0 0 1 1
Genital warts 14 3 0 6 23
None 103 57 46 144 350

Table 4: Correlation between new rapid TV antigen test and microscopy.

HIV( ) TV( ) n=154(%) HIV( ) TV(-) n=81(%) HIV(-) TV( ) n=54(%) HIV(-) TV(-) n=183(%) Total
Rapid TV Antigen Test 154(100.0) 81(100.0) 54(100.0) 183(100.0) 472
Microscopy TV detected 33(21.4) 0 14(25.9) 0 47(10)
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