Etiologies of genital inflammation and ulceration in symptomatic Rwandan men and women responding to radio promotions of free screening and treatment services

• Type of Material: Article
• Authors: Kristin Wall, Emory University; Julien Nyombayire, Rwanda Zambia HIV Research Group; Rachel Parker, Emory University; Rosine Ingabire, Rwanda Zambia HIV Research Group; Jean Bizimana, Rwanda Zambia HIV Research Group; Jeannine Mukamuyango, Rwanda Zambia HIV Research Group; Amelia Mazzei, Rwanda Zambia HIV Research Group; Matt A Price, University of California San Francisco; Marie Aimee Unyuzimana, Rwanda Zambia HIV Research Group; Amanda Tichacek, Emory University; Susan Allen, Emory University; Etienne Karita, Rwanda Zambia HIV Research Group
• Language: English
• Date: 2021-04-20
• Publisher: PUBLIC LIBRARY SCIENCE
• Publication Version: Final Published Version
• Copyright Statement: © 2021 Wall et al
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1371/journal.pone.0250044
• Title of Journal or Parent Work: PLOS ONE
• Volume: 16
• Issue: 4
• Start Page: e0250044
• End Page: e0250044
• Grant/Funding Information: This work was funded by the National Institutes of Health (NIH) (NIAID R01 AI51231), the NIH AIDS International Training and Research Program Fogarty International Center (D43 TW001042); and the NIH-funded Emory Center for AIDS Research (P30 AI050409). This work was partially funded by IAVI with the generous support of USAID and other donors; a full list of IAVI donors is available at https://www.iavi.org. The contents of this manuscript are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
• Keywords: Science & Technology; BACTERIAL VAGINOSIS; HIV-INFECTION; SEXUALLY-TRANSMITTED INFECTIONS; URETHRAL DISCHARGE; TRICHOMONAS-VAGINALIS; Multidisciplinary Sciences; FEMALE SEX WORKERS; SYNDROMIC MANAGEMENT; CHLAMYDIA-TRACHOMATIS; RISK-FACTORS; Science & Technology - Other Topics; NEISSERIA-GONORRHOEAE
• Research Categories: Health Sciences, Epidemiology; Health Sciences, Pathology

Abstract

Introduction The longstanding inadequacies of syndromic management for genital ulceration and inflammation are well-described. The Rwanda National Guidelines for sexually transmitted infection (STI) syndromic management are not yet informed by the local prevalence and correlates of STI etiologies, a component World Health Organization guidelines stress as critical to optimize locally relevant algorithms. Methods Radio announcements and pharmacists recruited symptomatic patients to seek free STI services in Kigali. Clients who sought services were asked to refer sexual partners and symptomatic friends. Demographic, behavioral risk factor, medical history, and symptom data were collected. Genital exams were performed by trained research nurses and physicians. We conducted phlebotomy for rapid HIV and rapid plasma reagin (RPR) serologies and vaginal pool swab for microscopy of wet preparation to diagnose Trichomonas vaginalis (TV), bacterial vaginosis (BV), and vaginal Candida albicans (VCA). GeneXpert testing for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were conducted. Here we assess factors associated with diagnosis of NG and CT in men and women. We also explore factors associated with TV, BV and VCA in women. Finally, we describe genital ulcer and RPR results by HIV status, gender, and circumcision in men. Results Among 974 men (with 1013 visits), 20% were positive for CT and 74% were positive for NG. Among 569 women (with 579 visits), 17% were positive for CT and 27% were positive for NG. In multivariate analyses, factors associated with CT in men included younger age, responding to radio advertisements, <17 days since suspected exposure, and not having dysuria. Factors associated with NG in men included not having higher education or full-time employment, <17 days since suspected exposure, not reporting a genital ulcer, and having urethral discharge on physical exam. Factors associated with CT in women included younger age and < = 10 days with symptoms. Factors associated with NG in women included younger age, lower education and lack of full-time employment, sometimes using condoms vs. never, using hormonal vs. non-hormonal contraception, not having genital ulcer or itching, having symptoms < = 10 days, HIV+ status, having BV, endocervical discharge noted on speculum exam, and negative vaginal wet mount for VCA. In multivariate analyses, only reporting >1 partner was associated with BV; being single and RPR+ was associated with TV; and having < = 1 partner in the last month, being pregnant, genital itching, discharge, and being HIV and RPR negative were associated with VCA. Genital ulcers and positive RPR were associated with being HIV+ and lack of circumcision among men. HIV+ women were more likely to be RPR+. In HIV+ men and women, ulcers were more likely to be herpetic rather than syphilitic compared with their HIV- counterparts. Conclusions Syndromic management guidelines in Rwanda can be improved with consideration of the prevalence of confirmed infections from this study of symptomatic men and women representative of those who would seek care at government health centers. Inclusion of demographic and risk factor measures shown to be predictive of STI and non-STI dysbioses may also increase diagnostic accuracy.