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Vaginal discharge unreliable predictor of STI
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Vaginal discharge was a poor predictor of sexually transmitted infection and did not increase susceptibility to HIV infection, according to data from the Centre for the AIDS Programme of Research in South Africa.
“The high rates of asymptomatic STIs mean that syndromic management of only symptomatic infections is far from adequate,” researcher Koleka Mlisana, PhD, of the University of KwaZulu Natal, South Africa, told Infectious Disease News. “Detection and prompt treatment of STIs form an integral component of HIV prevention. Our data highlight this important fact, demonstrated by the evidence that presence of one STI results in a three-fold risk of HIV acquisition.”
Researchers screened 775 high-risk women for HIV infection. Of these, 245 uninfected women were enrolled into the prospective observational cohort study. Participants attended the clinic monthly for risk-reduction counseling, to receive condoms and for HIV testing.
STI testing was done at enrollment at every 6 months, when the women received a gynecological exam. Two vaginal swab specimens were collected: one to detect bacterial vaginosis and one to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium and herpes simplex virus-2.
There was a high prevalence of laboratory-diagnosed STIs at enrollment: 20.3% had T. vaginalis, 5.4% had N. gonorrhoeae, 4.2% had C. trachomatis, 1.2% had M. genitalium and 3.7% were positive for HSV-2. Most of the women who were diagnosed with STIs were asymptomatic. Only 15.3% of women presented with vaginal discharge at enrollment, but only 27.5% of women were positive for an STI associated with vaginal discharge. Only 34.3% of vaginal discharge incidents were confirmed to be related to an STI. But among those who had an STI associated with discharge, 87.7% were asymptomatic.
Of the 245 women included in the study, 28 became infected with HIV. N. gonorrhoeae, C. trachomatis and M. genitalium were associated with HIV acquisition. Women who had one STI had a threefold risk for acquiring HIV, and women who had two or more STIs had a sixfold risk for acquiring HIV. HSV-2, bacterial vaginosis and vaginal discharge were not associated with an increased risk for HIV.
“This calls for regular screening in high risk individuals with the intention to diagnose and treat subclinical and therefore asymptomatic STIs,” Mlisana said. “This calls for the use of improved diagnostic assays such as nucleic acid detection. Consequently, it follows that improvement of laboratory infrastructure and adequate training of staff to support diagnosis of STIs is mandatory in high prevalence areas like South Africa.”
In an accompanying editorial, Myron S. Cohen, MD, of the University of North Carolina at Chapel Hill, discussed how the relationship between STIs and HIV transmission has commanded a lot of attention in the past years. He said the current study has expanded concerns about the apparent risk that having STIs has on the acquisition of HIV, and how to identify these women in low- to middle-income countries.
“Mlisana and colleagues argue for more frequent STI testing, using point-of-care assays where possible,” Cohen wrote. “This recommendation stems directly from our inability to know which women have an STI, as demonstrated in their report. The problem, of course, is that missing health care infrastructure and high relative costs for STI testing led to syndromic management of vaginal discharge in the first place, and these limitations have not been resolved.”
References:
Cohen MS. J Infect Dis. 2012;206;1-2.
Mlisana K. J Infect Dis. 2012;206:6-14.
Disclosures:
The researchers and Dr. Cohen report no relevant financial disclosures. .