STI and BV prevalence in young women in Cape Town and Soweto
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1 STI and BV prevalence in young women in Cape Town and Soweto Shaun Barnabas Genital Mucosal and STI lab Desmond Tutu HIV Foundation University of Cape Town FAMCRU University of Stellenbosch
2 WISH: Women s Initiative in Sexual Health 298 young women; years 149 peri-urban settlements around Cape Town prospective, longitudinal, cohort - seen for 3 visits 2 or 3 months apart 149 urban settlement in Johannesburg cross-sectional Behavioural and socio-demographic information at enrollment Genital sampling for STIs and inflammatory markers Standardized to two weeks after their contraceptive injection or in the luteal phase if on oral/barrier contraception
3 Sexual risk behaviour Characteristic Clinical site p-value Cape Town Johannesburg Number Heterosexual (n/n) 96% (123/126) 100% (104/104) Age in years [median (IQR)] 18 (17-20) 18 (17-20) Age of sexual debut (years) [median (IQR)] 16 (15-17) 16 (15-17) Lifetime number of sex partners [median (IQR)] 3 (1-13) 2 (1-10) Condom used always (n/n) 16% (20/126) 47% (49/104) Condom use during last sex act [% (n/n)] 76% (96/126) 90% (94/104) Sex with known/ suspected IV drug user (n/n) 1% (1/126) 11% (12/104) Ever used a vaginal drying agent used (n/n) 8% (10/126) 1% (2/104) Ever douched (n/n) 13% (16/126) 3% (3/104) Intergenerational relationship (>10yr age gap) [% (n/n)] 4% (5/126) 13% (13/104)
4 STIs: Cape Town and Johannesburg Type of infection Total Clinical site p-value Cape Town Johannesburg Chlamydia trachomatis (n/n) 30% (88/297) 42% (62/149) 18% (26/148) < Neisseria gonorrheae (n/n) 8% (24/297) 11% (17/149) 5% (7/148) Trichomonas vaginalis (n/n) 5% (16/297) 7% (11/149) 3% (5/148) Mycoplasma genitalium (n/n) 4% (11/297) 4% (6/149) 3% (5/148) Candidal hyphae and spores (n/n) 10% (30/291) 7% (10/149) 7% (10/143) HPV: High risk (n/n) 54% (135/252) 54% (80/149) 53% (55/103) Low risk (n/n) 42% (105/252) 46% (68/149) 36% (37/103) Multiple (n/n) 75% (123/163) 78% (78/100) 71% (45/63) HSV-2 DNA positive (n/n) 3% (8/297) 5% (7/149) 1% (1/148) HSV-2 Seropositive (n/n) na 21% (31/147) na na Bacterial vaginosis: Nugent score 7-10 (n/n) 47% (135/290) 47% (69/149) 42% (63/143) Intermediate Nugent 4-7 (n/n) 14% (41/290) 12% (17/149) 15% (23/143)
5 Cape Town longitudinal prevalence Characteristic Cape Town P-value Visit 1 Visit 2 Visit 3 N Bacterial vaginosis: Nugent score 7-10 [% (n/n)] 48% (71/147) 48% (61/126) 46% (39/84) Intermediate Nugent 4-6[% (n/n)] 12% (17/147) 9 %(11/126) 7% (6/84) Fungal hyphae and spores [% (n/n)] 7% (10/148) 11% (14/126) 13% (11/84) Viral infections: HPV [% (n/n)] 68% (100/147) 60% (75/126) 72% (64/88) HSV-2 DNA [% (n/n)] 5% (7/149) 27% (34/127) 27 %(24/88) HSV-2 IgG [% (n/n)] 21 (31/149) 27% (34/127) 27 %(24/88) Bacterial and Protozoal infections: Chlamydia trachomatis [% (n/n)] 42% (62/149) 34% (43/127) 18% (16/88) Neisseria gonorrhoeae [% (n/n)] 11% (17/149) 6% (8/127) 8% (7/88) Trichomonas vaginalis [% (n/n)] 7% (11/149) 8 %(10/127) 7% (6/88) Mycoplasma genitalium [% (n/n)] 4% (6/149) 6% (7/127) 7% (6/88) 1 000
6 STI prevalence by age categories Age categories year-old year-old year-old p-value Any STI [% (n/n)] 69.1% (65/94) 83.0% (88/106) 73.3% (55/75) Any bacterial STI 37.2% (35/94) 46.2% (49/106) 32.0% (24/75) C. trachomatis 33.0% (31/94) 35.8% (38/106) 22.6% (17/75) N. gonorrhoea 8.5% (8/94) 6.6% (7/106) 12.0% (9/75) T. vaginalis 3.2% (3/94) 7.5% (8/106) 4.0% (3/75) M. genitalium 3.2% (3/94) 4.7% (5/106) 2.7% (2/75) Any viral STI 62.8% (59/94) 71.7% (76/106) 62.7% (47/75) HSV-2 2.1% (2/94) 2.8% (3/106) 4.0% (3/75) HPV 57.4% (59/94) 73.1% (76/104) 63.0% (46/73) Multiple STIs 9.6% (9/94) 17.1% (18/105) 13.5% (10/74) Any STI with BV 38.3% (36/94) 40.9% (43/105) 27.0% (20/74) Any STI with Yeast 3/94 (3.2%) 4/105 (3.8%) 3/74 (4.0%) Any STI with Yeast and BV 1/94 (1.1%) 2/105 (1.9%) 5/74 (6.6%) 0.107
7 STI Management Guidelines
8 Clinical symptoms Cape Town Symptoms: Visit 1 Visit 2 Visit 3 P value Abnormal vaginal discharge [% (n/n)] 8% (3/39) 9% (5/58) 2% (1/58) Genital itching/burning [% (n/n)] 5% (2/39) 9% (5/58) 2% (1/58) Dysuria [% (n/n)] 5% (2/39) 5% (3/58) 5% (3/58) Any symptom [% (n/n)] 13% (5/39) 22% (13/58) 9% (5/58) 0.640
9 Sensitivity and specificity Sensitivity Sensitivity STI and BV STI only BV only Specificity
10 Clinical symptoms per condition 90% 80% 70% 60% Dysuria 50% 40% 30% 20% 10% Abnormal discharge Genital irritation 0%
11 Genital inflammation with and without symptoms VEGF SDF-1α IFN-ɣ IL-4 IL-1α IL-2Rα IL-10IL-1Rα IL IL IL-1β IL-6 IL-12(p40) IL-12(p70) IL-18 MIF TNF-α TNF-β TRAIL SCGF-β SCF PDGF-BB M-CSF LIF IL-9 1 0,1 CTACK Eotaxin GRO-α IL-8 IL-16 IP-10 IL-7 IL-3 HGF GM-CSF G-CSF FGF basic β-ngf MIG MIP-1α MIP-1β IFN-α2 MCP-3 MCP-1
12 Cummulative standardised beta-coefficients Association between STIs/BV and inflammation levels BV (n=71) TV (n=11) CT (n=62) NG (n=17) MG (n=6) IL-1RA IL-10 IL-2Rα IL-17 IL-13 IL-5 IL-4 IL-2 IFN-γ VEGF SDF-1α SCGF-β SCF PDGF-BB M-CSF LIF IL-9 IL-7 IL-3 HGF GM-CSF G-CSF FGF-basic β-ngf IFN-α2 RANTES MIP-1β MIP-1α MIG MCP-3 MCP-1 IP-10 IL-16 IL-8 GRO-α Eotaxin CTACK TRAIL TNF-β TNF-α MIF IL-18 IL-12p70 IL-12p40 IL-6 IL-1β IL-1α BV: Bacterial vaginosis TV: Trichomonas vaginalis CT: Chlamydia trachomatis NG: Neisseria gonorrhoeae MG: Mycoplasma genitalium
13 Inflammation: Cape Town vs Johannesburg IL-6 IL-7 IL-10 GROα MIF SCF MCP-1 MIP-1β VEGF
14 Differential inflammatory profiles between sites Bacterial vaginosis Chlamydia trachoma s CTACK Eotaxin TNF-a TNF-b TRAIL IL-12p40 IL-6 IL-12(p70) IL-18 MIF IL-1b IL-1a IL-1ra 8 IL-10 IL-2Ra IL-17 6 IL-13 IL-5 4 IL-4 IL-2 2 IFN-g 0 VEGF -2 SDF-1a -4 SCGF-b -6 SCF BV-cpt BV-jhb TNF-b TRAIL CTACK Eotaxin TNF-a IL-12p40 IL-6 IL-12(p70) IL-18 MIF IL-1b IL-1a IL-1ra 3 IL-10 IL-2Ra IL IL-13 IL-5 2 IL IL IFN-g VEGF SDF-1a SCGF-b SCF CT-cpt CT-jhb GROa PDGF-bb GROa PDGF-bb IFN-a2 M-CSF IFN-a2 M-CSF IL-16 LIF IL-16 LIF IL-8 IP-10 MCP-1 MCP-3 MIG MIP-1a MIP-1b RANTES IL-7 IL-3 HGF GM-CSF G-CSF b-ngf FGF basic IL-9 IL-8 IP-10 MCP-1 MCP-3 MIG MIP-1a MIP-1b RANTES IL-7 IL-3 HGF GM-CSF G-CSF b-ngf FGF basic IL-9 Inflammatory Chemokine Growth factors Adaptive Regulatory
15 Summary High burden of BV and STIs Higher prevalence of chlamydia & gonorrhea in Cape Town Poor correlation symptoms and microbiological diagnosis BV induced a higher inflammatory environment compared to STIs Chlamydia infection was more inflammatory in Johannesburg than in Cape Town
16 Acknowledgments Jo-Ann Passmore, Smritee Dabee, Shameem Jaumdally, Hoyam Gamieldien Linda-Gail Bekker, Penelope Ngcobo, Dante Robertz, Thola Bennie & Youth Centre staff Anna-Lise Williamson & Zizipho Mbulawa Glenda Gray, Janan Dietrich & PHRU staff Lynn Morris, Nonhlanla Mkhize, Raveshni Durgiah David Lewis & Venessa Maseko Heather Jaspan All the participants Lindi Masson
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