Tendesayi Kufa

We conducted a cross-sectional study to estimate the prevalence of urogenital and extragenital sexually transmitted infections (STIs) among men who have sex with men (MSM) with and without urethral discharge syndrome, to assess infections missed by syndromic management, and to describe phenotypic antimicrobial susceptibility patterns of Neisseria gonorrhoeae . The study included 189 MSM attending the Engage Men’s Health Clinic in Johannesburg, South Africa, in 2024. Urethral, rectal and oropharyngeal swabs were tested by multiplex PCR for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV). Genital ulcer swabs were tested for HSV-1/2, lymphogranuloma venereum (LGV), Haemophilus ducreyi (HD) and Treponema pallidum (TP). Serological diagnostic testing for HIV, hepatitis B virus (HBV) and syphilis was performed. NG isolates underwent culture and antimicrobial susceptibility testing. Among MSM with urethritis, NG was most prevalent (urethra: 80.3%, rectum: 41.7%), followed by CT (urethra: 14.8%, rectum: 11.7%). Pharyngeal NG was more common among MSM with urethritis than those without (18.0% vs 3.1%, p = 0.001). Among MSM without urethritis, rectal NG and CT prevalence were 13.5% and 9.5%; rectal LGV was detected in three cases. Among 22 participants with genital ulcers, an aetiology was identified in eight: HSV-2 (n = 3), TP (n = 4) and LGV (n = 1). All NG isolates were susceptible to ceftriaxone, cefixime, and azithromycin, and had low MICs of gentamicin. HIV, HBsAg and treponemal antibody seroprevalence were 31.4%, 3.2% and 50.8%. Active syphilis (RPR titres ≥1:32) was more frequent among MSM without urethral symptoms. Among MSM with urethritis, CT infection was less likely in those reporting recent insertive oro-anal sex and HIV pre-exposure prophylaxis (PrEP) use. Among MSM without urethritis, any discharge STI was associated with homosexual orientation, HIV positivity and lack of circumcision, NG with HIV positivity and being uncircumcised and CT with HIV positivity. Extragenital and asymptomatic STIs remain common among MSM in Johannesburg, stressing the need for routine multi-site molecular screening and inclusion of rapid serological syphilis testing in national STI guidelines for key populations.

The Southern African Journal of HIV Medicine is focused on HIV/AIDS treatment, prevention and related topics relevant to clinical and public health practice. The purpose of the journal is to disseminate original research results and support high-level learning related to HIV Medicine. It publishes original research articles, editorials, case reports/case series, reviews of state-of-the-art clinical practice and correspondence.

Background: There is an urgent need to improve interventions for HIV and syphilis in pregnancy to achieve elimination. Results: The tenets of vertical transmission strategies for HIV and syphilis overlap but have varying success due to differences in their transmission dynamics, diagnoses, and treatment. Key principles include prevention of maternal infection, screening and diagnosis early and throughout antenatal care, curative treatment (syphilis), viral load suppression (HIV), early infant diagnosis and treatment (HIV and congenital syphilis). We recommend improved guidelines, provider training and focused research and surveillance, including implementation studies to align HIV and syphilis screening and treatment during pregnancy. Opportunities to integrate syphilis screening and treatment into antenatal and HIV care enable providers to offer comprehensive maternal care. Conclusion: Integrated HIV/syphilis services ensure a cohesive and person-centered approach, improving health outcomes through streamlined, efficient, and family-centered care pathways. We recommend key interventions to reduce HIV and syphilis in pregnancy and prevent vertical transmission.

Background: Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA). Methods and findings: We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies. Conclusions: In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management. PROSPERO number: CRD42022348045.

Background: Accurate measurement of antenatal antiretroviral treatment (ART) coverage in pregnancy is imperative in tracking progress towards elimination of vertical HIV transmission. In the Western Cape, South Africa, public-sector individual-level routine data are consolidated from multiple sources, enabling the description of temporal changes in population-wide antenatal antiretroviral coverage. We evaluated the validity of different methods for measuring ART coverage among pregnant women. Methods: We compared self-reported ART data from a 2014 antenatal survey with laboratory assay data from a sub-sample within the survey population. Thereafter, we conducted a retrospective cohort analysis of all pregnancies consolidated in the Provincial Health Data Centre (PHDC) from January 2011 to December 2020. Evidence of antenatal and HIV care from electronic platforms were linked using a unique patient identifier. ART coverage estimates were triangulated with available antenatal survey estimates, aggregated programmatic data from registers recorded in the District Health Information System (DHIS) and Thembisa modelling estimates. Results: Self-reported ART in the 2014 sentinel antenatal survey (n = 1434) had high sensitivity (83.5%), specificity (94.5%) and agreement (k = 0.8) with the gold standard of laboratory analysis of ART. Based on linked routine data, ART coverage by the time of delivery in mothers of live births increased from 67.4% in 2011 to 94.7% by 2019. This pattern of increasing antenatal ART coverage was also seen in the DHIS data, and estimated by the Thembisa model, but was less consistent in the antenatal survey data. Conclusion: This study is the first in a high-burden HIV setting to compare sentinel ART surveillance data with consolidated individuated administrative data. Although self-report in survey conditions showed high validity, more recent data sources based on self-report and medical records may be uncertain with increasing ART coverage over time. Linked individuated data may offer a promising option for ART coverage estimation with greater granularity and efficiency.

Background: Dual HIV/syphilis testing may be an acceptable intervention to identify men with sexually transmitted infections (STIs) and at risk of HIV acquisition. Objectives: We sought to determine the acceptability, and performance of dual HIV/syphilis testing among men attending voluntary medical male circumcision (VMMC) services at six public sector facilities in Gauteng. Method: This was a cross-sectional study at VMMC facilities. Men ≥ 18 years were enrolled. The men had (1) a questionnaire administered, (2) on-site dual HIV/syphilis testing with First Response HIV1+2/Syphilis Combo Card Test by routine lay counsellors, and (3) a blood specimen collected for centralised laboratory testing for HIV and syphilis serology. We evaluated pre-test and post-test acceptability and performance compared to serological testing. Results: Of the 679 men analysed (median age 32.1 years), 96.7% of HIV-negative men preferred testing for HIV and syphilis simultaneously. Of the 675 men tested for syphilis, 28 (4.7%) tested positive (past or recent). In the laboratory, 43/609 (7.1%) had syphilis infection detected, with 9/609 (1.5%) having recent syphilis. There was sub-optimal sensitivity for HIV detection (90.9%; 95% confidence interval [CI]: 88.5% – 93.3%), and for past/recent syphilis (55.8%; 95% CI: 51.9% – 59.8%), improving to 88.9% (95% CI: 86.4% – 91.4%) for recent syphilis. Specificities were > 99% for HIV and syphilis (past or recent). Post-test acceptability was 96.6% and willingness to pay for future testing was 86.1%. Conclusion: Dual HIV/syphilis testing was acceptable but had sub-optimal sensitivity for HIV and syphilis. Syphilis detection was adequate for recent infection.

Syphilis, ‘the great imitator’, caused by Treponema pallidum infection, remains a complex and multifaceted disease with a rich history of clinical diversity. This guideline aims to be a comprehensive guide for healthcare workers in Southern Africa, offering practical insights into the epidemiology, pathogenesis, clinical manifestations, diagnostic testing, therapeutic principles, and public health responses to syphilis. Although the syphilis burden has declined over the years, recent data indicate a troubling resurgence, particularly among pregnant women and neonates. This guideline highlights the diagnostic challenges posed by syphilis, stemming from the absence of a single high-sensitivity and -specificity test. While treatment with penicillin remains the cornerstone of treatment, alternative regimens may be used for specific scenarios. We highlight the importance of thorough patient follow-up and management of sex partners to ensure optimal care of syphilis cases. In the context of public health, we emphasise the need for concerted efforts to combat the increasing burden of syphilis, especially within high-risk populations, including people living with HIV.

Introduction: Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings lacking aetiologic diagnostics. However, heterogeneity in underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review characterised aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA). Methods: We searched Embase, MEDLINE, Global Health, and Web of Science until July 25, 2022, and grey literature until August 31, 2022, for studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance and used generalised linear mixed-effects meta-regressions to estimate aetiologic distributions, trends, and determinants. Results: Of 4136 identified records, 198 reports were included from 183 studies in 32 countries between 1969 and 2022. In 2015, primary aetiologies for vaginal discharge were candidiasis (69.4% [95% CI:44.1-86.6%], n=50), bacterial vaginosis (50.0% [32.3-67.8%], n=39), chlamydia (16.5% [8.7-29.0%], n=49), and trichomoniasis (12.9% [7.7-20.7%], n=78); for urethral discharge were gonorrhoea (78.8% [70.9-85.1%], n=67) and chlamydia (22.2% [16.0-30.1%], n=48); and for genital ulcer were HSV-2 (56.1% [39.2-71.6%], n=46) and syphilis (7.8% [5.3-11.4%], n=115). Regional variation was marginal. Temporal variation was substantial, particularly for genital ulcer. For each symptom, HIV-status and age were significantly associated with infection diagnoses, although aetiologic hierarchies were largely the same by strata. Conclusion: Syndrome aetiologies in SSA align with WHO guidelines without strong evidence of contextual or demographic variation, supporting broad guideline applicability. Temporal changes underscore the need for aetiologic re-assessment. STI surveillance using syndrome-based assessments is noncomprehensive and requires studies among symptomatic and asymptomatic populations.