Prevalence of Chlamydia and Gonorrhea Among Patients With Genital Ulcer Disease in Zimbabwe:

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2 Prevalence of Chlamydia and Gonorrhea Among Patients With Genital Ulcer Disease in Zimbabwe: Potential Implications for Syndromic Management More Mungati: MBChB, MPH Zimbabwe Ministry of Health and Child Care University of Zimbabwe, Department of Community Medicine

3 Introduction Laboratory testing for Sexually Transmitted Infections (STIs) is not routinely available in Zimbabwe Therefore syndromic approach used in Zimbabwe and other developing countries Surveillance and sentinel lab testing are vital for developing treatment guidelines

4 Introduction Syndromic treatment for genital ulcer disease (GUD) includes Benzathine penicillin, erythromycin, and acyclovir Patients with co-existent gonorrhoea or chlamydia infections are not adequately treated unless they have concomitant genital discharge Chlamydia and gonorrhoea are frequently asymptomatic CT in women (70%) and men (30%) NG in women (80%) and men (10%)

5 Introduction How common are chlamydia and/or gonorrhoea infections in patients with GUD? What is the likelihood that these patients are not treated for these co-infections when using the syndromic approach?

6 Methods This study was part of a larger cross sectional study to determine the etiology of STI syndromes in Zimbabwe Men with urethral discharge (n=200) Women with vaginal discharge (n=200) Men and women with genital ulcer disease (n=200)

7 Results

8 Results Enrollment completed, 600 enrolled Of 100 men and 100 women with GUD Full results available for 100 women and 98 men Specimens for 2 men inadequate

9 Percentage Aetiology of Genital Ulcer Disease, Zimbabwe: HSV T. Pallidum LGV H. Ducreyi Infecting Organism Male Female

10 Percentage Prevalence of Gonorrhoea and Chlamydia among Different Syndromes, Zimbabwe: Gonorrhoea Chlamydia Male Discharge Syndrome By Xpert CT/NG Female Discharge Syndrome Female Genital Ulcer Disease Sexually Transmitted Syndrome Male Genital Ulcer Disease

11 Percentage Infection with Gonorrhoea and/or Chlamydia, Zimbabwe: By Xpert CT/NG 34.5 Female Discharge Syndrome 29 Female Genital Ulcer Disease Sexually Transmitted Syndrome 23.5 Male Genital Ulcer Disease

12 Percentage Eligibility for Simultaneous Genital Discharge Syndrome Management, Zimbabwe: % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% By Xpert CT/NG Female Genital Ulcer Disease Genital Ulcer Disease Male Genital Ulcer Disease Eligible Not Eligible

13 Results Of the 52 men and women with GUD who were coinfected with chlamydia and gonorrhoea 36 (69%) were not eligible for genital discharge syndrome management This represents 18.2% of all patients with GUD in our study

14 Discussion Syndromic management of STIs effectively Treats symptomatic patients Treats mixed infections Avoids expensive tests High prevalence of CT/NG in asymptomatic patients % (Detels et al 2011); Causes PID, subfertility 8.7% (Nwankwo et al 2014) Prevalence of CT/NG in women with vaginal discharge is similar to men/women with GUD

15 Limitations Only patients with symptomatic STIs studied Possible over-sampling of high risk patients

16 Conclusions Gonococcal and chlamydia infections present in 26% of GUD cases. 69% would not have been treated Results raises concerns on the syndromic approach for genital ulcer disease

17 Next Steps So what are the alternatives: Ignore this high prevalence of CT/NG among patients with GUD? Screen all patients with GUD for chlamydia and gonorrhoea? Treat all patients with GUD for chlamydia and gonorrhoea?

18 Zimbabwe STI Aetiology Study Research Team DCM/SEAM/ZiCHIRE Prof. Mufuta Tshimanga Dr. Gerald Shambira Mr. Vitalis Kupara Ms. Luanne Rodgers Ministry of Health and Child Care Dr. Owen Mugurungi Dr. More Mungati Ms. Anna Machiha Mr. Justice Nyakura U.S. Centers for Disease Control and Prevention Dr. Peter Kilmarx Ms. Elizabeth Gonese Dr. Amy Herman-Roloff Consultants Prof. David Lewis University of Sydney, Western Sydney Sexual Health Prof. Hunter Handsfield University of Washington Prof. Kees Rietmeijer Rietmeijer Consulting, USA

19 Collaboration Zimbabwe Ministry of Health and Child Care University of Zimbabwe, Department of Community Medicine Centers for Disease Control and Prevention

20 Funding This project has been supported by the United States President s Emergency Plan for AIDS Relief (PEPFAR) through Cooperative Agreement between the Centers for Disease Control and Prevention and the University of Zimbabwe Department of Community Medicine SEAM Project under the terms of Cooperative Agreement Number: 1U2GGH

21 Thank You