Call to action for health systems integration of point-of-care testing to mitigate the transmission and burden of sexually transmitted infections.

OBJECTIVES: In 2016, WHO estimated 376 million new cases of the four main curable STIs: gonorrhoea, chlamydia, trichomoniasis and syphilis. Further, an estimated 290 million women are infected with human papillomavirus. STIs may lead to severe reproductive health sequelae. Low-income and middle-income countries carry the highest global burden of STIs. A large proportion of urogenital and the vast majority of extragenital non-viral STI cases are asymptomatic. Screening key populations and early and accurate diagnosis are important to provide correct treatment and to control the spread of STIs. This article paints a picture of the state of technology of STI point-of-care testing (POCT) and its implications for health system integration. METHODS: The material for the STI POCT landscape was gathered from publicly available information, published and unpublished reports and prospectuses, and interviews with developers and manufacturers. RESULTS: The development of STI POCT is moving rapidly, and there are much more tests in the pipeline than in 2014, when the first STI POCT landscape analysis was published on the website of WHO. Several of the available tests need to be evaluated independently both in the laboratory and, of particular importance, in different points of care. CONCLUSION: This article reiterates the importance of accurate, rapid and affordable POCT to reach universal health coverage. While highlighting the rapid technical advances in this area, we argue that insufficient attention is being paid to health systems capacity and conditions to ensure the swift and rapid integration of current and future STI POCT. Unless the complexity of health systems, including context, institutions, adoption systems and problem perception, are recognised and mapped, simplistic approaches to policy design and programme implementation will result in poor realisation of intended outcomes and impact.

Microbiota in vaginal health and pathogenesis of recurrent vulvovaginal infections: a critical review.

Recurrent vulvovaginal infections (RVVI) has not only become an epidemiological and clinical problem but also include large social and psychological consequences. Understanding the mechanisms of both commensalism and pathogenesis are necessary for the development of efficient diagnosis and treatment strategies for these enigmatic vaginal infections. Through this review, an attempt has been made to analyze vaginal microbiota (VMB) from scratch and to provide an update on its current understanding in relation to health and common RVVI i.e. bacterial vaginosis, vulvovaginal candidiaisis and Trichomoniasis, making the present review first of its kind. For this, potentially relevant studies were retrieved from data sources and critical analysis of the literature was made. Though, culture-independent methods have greatly unfolded the mystery regarding vaginal bacterial microbiome, there are only a few studies regarding the composition and diversity of vaginal mycobiome and different Trichomonas vaginalis strains. This scenario suggests a need of further studies based on comparative genomics of RVVI pathogens to improve our perceptive of RVVI pathogenesis that is still not clear (Fig. 5). Besides this, the review details the rationale for Lactobacilli dominance and changes that occur in healthy VMB throughout a women's life. Moreover, the list of possible agents continues to expand and new species recognised in both health and VVI are updated in this review. The review concludes with the controversies challenging the widely accepted dogma i.e. "VMB dominated with Lactobacilli is healthier than a diverse VMB". These controversies, over the past decade, have complicated the definition of vaginal health and vaginal infections with no definite conclusion. Thus, further studies on newly recognised microbial agents may reveal answers to these controversies. Conversely, VMB of women could be an answer but it is not enough to just look at the microbiology. We have to look at the woman itself, as VMB which is fine for one woman may be troublesome for others. These differences in women's response to the same VMB may be determined by a permutation of behavioural, cultural, genetic and various other anonymous factors, exploration of which may lead to proper definition of vaginal health and disease.

[CLINICAL CASE OF TRICHOMONAS VAGINALIS INVASION OF THE PREGNANT WOMAN AND HER NEWBORN GIRL].

Objective - study of the features of Trichomonas vaginalis invasion in pregnant women and newborns. The cultures of Trichomonas isolated from a pregnant woman, her newborn girl, as well as amniotic fluid were examined. The ultrastructure of the cells was studied using a TEM-125K microscope equipped with a SAI-01A system (SELMI), using a DX 2 CCD camera and the KAPPA software package. The verification of STI pathogens was carried out by PCR, in particular, Trichomonas tenax and Pentatrichomonas hominis were identified by experimental original primers that were developed using real-time PCR (PCR-RT). The invasion of Trichomonas vaginalis of the genital tract of a newborn girl, amniotic fluid and amniotic membrane is characterized clinically and instrumentally. We proved the possibility of Trichomonas vaginalis invasion of newborn children not only during the passage of the child through the infected birth canal, but also due to a defect in the fetal membranes with the development of chorioamnionitis, followed by infection of the amniotic fluid and possible infection of the fetus.

Use of Internal Transcribed Spacer Sequence Polymorphisms as a Method for Trichomonas vaginalis Genotyping.

OBJECTIVE: Trichomonas vaginalis is the most common non-viral, sexually transmitted pathogen with a worldwide distribution. The aim of the present study was to design a new genotyping tool for T. vaginalis isolates using internal transcribed spacer (ITS) sequences. METHODS: First, a total of 20 cryopreserved T. vaginalis isolates were thawed and genomic DNA was isolated from fresh cultures. A polymerase chain reaction (PCR) was performed to amplify the ITS regions and the amplicons were sequenced. These sequences were aligned with others from Genbank and polymorphisms were detected. At last, each ITS sequence was given a different sequence type. RESULTS: More than 99% homology was observed among sequences. Of 20 isolates, five had identical ITS sequence to reference (L29561) defined as ITST1. Moreover, 13 had A58 deletion (ITST10), one had C203T mutation (ITST2), and one had both A58 deletion and C203T mutation (ITST11). ITS typing of T. vaginalis sequences on Genbank revealed a total of 11 ITS types with the predominance of ITST1 (44.4%) globally. CONCLUSIONS: ITS typing seems to be an applicable and useful tool for a better understanding of molecular epidemiology as well as for the dissemination of T. vaginalis clones.

A cross-sectional analysis of Trichomonas vaginalis infection among heterosexual HIV-1 serodiscordant African couples.

OBJECTIVES: Trichomonas vaginalis is the most prevalent curable STI worldwide and has been associated with adverse health outcomes and increased HIV-1 transmission risk. We conducted a cross-sectional analysis among couples to assess how characteristics of both individuals in sexual partnerships are associated with the prevalence of male and female T. vaginalis infection. METHODS: African HIV-1 serodiscordant heterosexual couples were concurrently tested for trichomoniasis at enrolment into two clinical trials. T. vaginalis testing was by nucleic acid amplification or culture methods. Using Poisson regression with robust standard errors, we identified characteristics associated with trichomoniasis. RESULTS: Among 7531 couples tested for trichomoniasis, 981 (13%) couples contained at least one infected partner. The prevalence was 11% (n=857) among women and 4% (n=319) among men, and most infected individuals did not experience signs or symptoms of T. vaginalis. Exploring concordance of T. vaginalis status within sexual partnerships, we observed that 61% (195/319) of T. vaginalis-positive men and 23% (195/857) of T. vaginalis-positive women had a concurrently infected partner. In multivariable analysis, having a T. vaginalis-positive partner was the strongest predictor of infection for women (relative risk (RR) 4.70, 95% CI 4.10 to 5.38) and men (RR 10.09, 95% CI 7.92 to 12.85). For women, having outside sex partners, gonorrhoea, and intermediate or high Nugent scores for bacterial vaginosis were associated with increased risk of trichomoniasis, whereas age 45 years and above, being married, having children and injectable contraceptive use were associated with reduced trichomoniasis risk. Additionally, women whose male partners were circumcised, had more education or earned income had lower risk of trichomoniasis. CONCLUSIONS: We found that within African HIV-1 serodiscordant heterosexual couples, the prevalence of trichomoniasis was high among partners of T. vaginalis-infected individuals, suggesting that partner services could play an important role identifying additional cases and preventing reinfection. Our results also suggest that male circumcision may reduce the risk of male-to-female T. vaginalis transmission.

Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies.

Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection worldwide. Annually, 7.4 million new infections are estimated in the United States, which is greater than combined new cases of Chlamydia, gonorrhea, and syphilis. Serious adverse reproductive health outcomes including pregnancy complications, pelvic inflammatory disease, and an increased risk of HIV acquisition have been linked to TV infection. There are several sensitive and specific diagnostic tests available, including a newly approved nucleic acid amplification test (NAAT) that utilizes the same instrumentation platform and clinical sample as Chlamydia and gonorrhea tests. In this article, we review TV pathogenicity, adverse reproductive health outcomes, detection, and treatment followed by clinical scenarios for which TV diagnosis may prove useful in obstetrics and gynecology practice.

Sexually transmitted infection prevalence in symptomatic adolescent emergency department patients.

OBJECTIVES: This study aimed to determine the prevalence of sexually transmitted infections (STIs) in symptomatic adolescent female patients presenting to a pediatric emergency department (ED). Secondary objectives included determining correlates of infection. METHODS: This was a prospective prevalence study of a consecutive sample of female patients aged 14 to 19 years presenting to a pediatric ED with lower-abdominal or genitourinary complaints between August 2009 and January 2010. Patients were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Descriptive statistics, sensitivity analysis to account for untested patients, and logistic regression to understand correlates of STI were performed. RESULTS: A total of 276 patients met inclusion criteria; 236 underwent STI testing. The prevalence of any STI was 26.3% (95% confidence interval [CI], 20.6%-31.9%) among patients who had testing performed, with C. trachomatis infection being most prevalent (19.7%; 95% CI, 14.5%-24.9%). Assuming all eligible patients who did not undergo STI testing were not infected, sensitivity analysis revealed a minimum STI prevalence of 22.5% (95% CI, 17.5%-27.4%). Multivariable logistic regression revealed no significant association between STI and patient age, chief complaint, or insurance status. There was a significant association between STI and black or African-American race (odds ratio, 9.5; 95% CI, 2.1-44.1). CONCLUSIONS: A large percentage of our study population had an STI, and therefore, STI testing should be considered in all symptomatic adolescent ED female patients. Future studies should focus on understanding barriers to STI testing and designing interventions to increase testing within an adolescent ED population.

Genotypic characterization of Trichomonas vaginalis isolates among women who have sex with women in sexual partnerships.

The random amplified polymorphic DNA technique was used to delineate the genetic relatedness of Trichomonas vaginalis isolates among 3 pairs of mutually infected women who have sex with women in sexual partnerships. One of the 3 pairs of women shared a T. vaginalis isolate with the same random amplified polymorphic DNA banding patterns. Shared use of washcloths to cleanse the vaginal area after receptive oral sex was the most likely method of T. vaginalis transmission among this pair of women.

Sexual health and the Rugby World Cup 2011: a cross-sectional study of sexual health clinics in New Zealand.

BACKGROUND: We aimed to describe the characteristics of sexual health clinic (SHC) attendance and sexually transmissible infection (STI) diagnoses during the Rugby World Cup (RWC) in New Zealand in 2011. METHODS: SHC attendance and STI diagnoses around the time of the RWC were compared with the 5 preceding years. A cross-sectional survey conducted at SHCs in four New Zealand cities collected information from attendees having RWC-related sex. RESULTS: Although there was no statistically significant increase in clinic attendance or STI diagnoses during the RWC compared with previous years, in these four cities, 151 individuals of 2079 attending SHCs for a new concern reported RWC-related sex. The most frequently diagnosed STIs were chlamydial infection (Chlamydia trachomatis), genital warts and genital herpes. Most attendees (74%) who had RWC-related sex had consumed three or more alcoholic drinks; 22% had used a condom. Seven percent of women reported nonconsensual sex. RWC-related sex was associated with an increased risk of STI diagnoses in men: gonorrhoea (Neisseria gonorrhoeae): relative risk (RR)=4.9 (95% confidence interval (CI): 2.1-11.4); nonspecific urethritis: RR=2.8 (95% CI: 1.3-5.9); chlamydial infection: RR=1.8 (95% CI: 1.1-2.9). Using a condom was associated with a reduced risk (RR=0.3, 95% CI: 0.1-0.9) of diagnosis with any STI among those having RWC-related sex. CONCLUSIONS: These findings highlight issues that are amenable to prevention. The continued promotion of condoms as well as a reduction in the promotion and availability of alcohol at such events may reduce sexual health risks as well as other harm.

[Trichomonas vaginalis prevalence in sex workers]. / Prevalencia de Trichomonas vaginalis en trabajadores sexuales.

Trichomoniasis is a sexually transmitted infection (STI) usually associated to vaginitis, urethritis, cervicitis and pelvic inflammatory disease, which can cause infertility. The aim of this retrospective longitudinal study was to determine Trichomonas vaginalis prevalence in a population of male and female sex workers in Mendoza, Argentina. A cohort of 720 people who attended the STI Program in this province was retrospectively analyzed. From February 2007 up to June 2009, 1692 samples were processed using a reposition sampling method. The age and sex distribution of the population was: 687 women/33 men, from 15 to 65 years old. Trichomoniasis prevalence determined for this population at risk was 7.6% in women only, men did not present infection. The high prevalence shown for this risk group suggests a great vulnerability of this population to contract other more serious STIs. In another sense, it also shows a remarkable lack in the use of mechanical barriers to prevent sexually transmitted diseases (STDs). The present research justifies the elaboration of standardized procedures guide to diagnose T. vaginalis within the framework of the Reproductive Health Program (PROSAR).

Prevalencia de Trichomonas vaginalis en trabajadores sexuales / Trichomonas vaginalis prevalence in sex workers

La tricomoniasis es una infección de transmisión sexual (ITS) que se asocia a vaginitis, uretritis, cervicitis y enfermedad inflamatoria pélvica pudiendo producir infertilidad tubárica. El objetivo de este trabajo, de tipo retrospectivo longitudinal, fue determinar la prevalencia de Trichomonas vaginalis en una población de trabajadores sexuales en Mendoza, Argentina. Se estudió en forma retrospectiva una población de 720 personas asistidas por el Programa Provincial de ITS de Mendoza. Entre febrero de 2007 y junio de 2009 se procesaron 1692 muestras con un muestreo por reposición. La distribución por sexo fue de 687 mujeres y 33 varones con edades comprendidas entre 15 y 65 años. La prevalencia de tricomoniasis determinada en esta población en riesgo fue de 7.6% para las mujeres, sin encontrarse infecciones en el grupo de los hombres. La prevalencia hallada en este grupo en riesgo muestra una población con alta vulnerabilidad para contraer otras ITS de mayor gravedad. En otro sentido, sugiere una importante falta de adhesión al uso de barreras mecánicas para prevenir infecciones de transmisión sexual. Este trabajo justifica la elaboración de una guía de procedimientos para el manejo de la infección por tricomonas en el marco del Programa de Salud Reproductiva (PROSAR).

Trichomoniasis is a sexually transmitted infection (STI) usually associated to vaginitis, urethritis, cervicitis and pelvic inflammatory disease, which can cause infertility. The aim of this retrospective longitudinal study was to determine Trichomonas vaginalis prevalence in a population of male and female sex workers in Mendoza, Argentina. A cohort of 720 people who attended the STI Program in this province was retrospectively analyzed. From February 2007 up to June 2009, 1692 samples were processed using a reposition sampling method. The age and sex distribution of the population was: 687 women/33 men, from 15 to 65 years old. Trichomoniasis prevalence determined for this population at risk was 7.6% in women only, men did not present infection. The high prevalence shown for this risk group suggests a great vulnerability of this population to contract other more serious STIs. In another sense, it also shows a remarkable lack in the use of mechanical barriers to prevent sexually transmitted diseases (STDs). The present research justifies the elaboration of standardized procedures guide to diagnose T. vaginalis within the framework of the Reproductive Health Program (PROSAR).

Non-sexual transmission of Trichomonas vaginalis in adolescent girls attending school in Ndola, Zambia.

OBJECTIVES: To identify risk factors for trichomoniasis among young women in Ndola, Zambia. METHOD: The study was a cross-sectional study among adolescent girls aged 13-16 years in Ndola, Zambia. Study participants were recruited from schools in selected administrative areas that represented the different socio-economic strata in town. Consenting participants were interviewed about their socio-demographic characteristics; sexual behaviour; and hygiene practices. Self-administered vaginal swabs were tested for Trichomonas vaginalis. HSV-2 antibodies were determined on serum to validate the self-reported sexual activity. RESULTS: A total of 460 girls participated in the study. The overall prevalence of trichomoniasis was 27.1%, 33.9% among girls who reported that they had ever had sex and 24.7% among virgins. In multivariate analysis the only statistically significant risk factor for trichomoniasis was inconsistent use of soap. For the virgins, none of the risk factors was significantly associated with trichomoniasis, but the association with use of soap (not always versus always) and type of toilet used (pit latrine/bush versus flush toilet) was of borderline significance. CONCLUSION: We found a high prevalence of trichomoniasis in girls in Ndola who reported that they had never had sex. We postulate that the high prevalence of trichomoniasis in virgins in Ndola is due to non-sexual transmission of trichomoniasis via shared bathing water and inconsistent use of soap.

Non-monogamy and risk of infection with Chlamydia trachomatis and Trichomonas vaginalis among young adults and their cohabiting partners in Peru.

OBJECTIVES: To determine how patterns of non-monogamy influence prevalences of sexually transmitted infections (STIs) in individuals and their cohabitating sex partners. METHODS A 2002 survey in 24 Peruvian cities enrolled men and women aged 18-29 years from random household samples. The cohabiting sex partner of each enrolee was also enrolled until approximately 100 couples per city were recruited. Men provided urine and women vaginal swabs or urine for molecular testing for Chlamydia trachomatis and Trichomonas vaginalis; both genders provided blood for serological testing. RESULTS: Among 2099 females and 2052 males providing specimens and behavioural data, 18.2% of males and 2.5% of females reported non-monogamy during the past year. C trachomatis was detected in 121 females (5.8%) and 80 males (4.1%) and T vaginalis in 87 females (4.2%) and 26 males (1.3%). Multivariate analyses showed that C trachomatis infection in females was significantly associated with her male partner's non-monogamy (OR 2.02, CI 1.32 to 3.08) but not significantly with her own non-monogamy; T vaginalis was associated with her own non-monogamy (OR 3.11, CI 1.25 to 7.73) and with her partner's non-monogamy (OR 2.07, CI 1.26 to 3.42). For males, both C trachomatis (OR 2.17, CI 1.29 to 3.69) and T vaginalis (OR 2.49, CI 1.06 to 5.87) were significantly associated only with his own non-monogamy. CONCLUSIONS: Among cohabiting couples, male non-monogamy was common and was associated with C trachomatis and T vaginalis infection in himself and in his female partner, whereas female non-monogamy was reported infrequently and was significantly associated only with her own T vaginalis infection. Patterns of non-monogamy may guide public health interventions.

Iatrogenic transmission of Trichomonas vaginalis by a traditional healer.

A woman presenting to an STI/HIV clinic in The Gambia with T vaginalis and a history of a digital vaginal 'exam' by a traditional healer implies non-sexual transmission of trichomonas between patients and reinforces the role of practitioner hygiene in preventing spread of infections.

[Clinical laboratory diagnosis of trichomoniasis in patients with internal diseases].

Urogenital trichomoniasis is an infectious inflammatory disease of the urogenital system caused by protozoan Trichomonas vaginalis and characterized by rapid dissemination and development of complications. Because laboratory diagnosis by microscopic methods encounters difficulty, we undertook detection of T. vaginalis by microscopic study of native and stained (methylene blue, acridine orange, Gram, Romanovsky-Giemsa) uretheral scrapings. 69 patients having no clinical signs of the disease were examined after sexual contacts with women suffering infection of the urogenital tract. Staining with acridine orange and by Romanovsky-Giemsa method proved the most informative methods for diagnosis of torpid trichomoniasis (85.5 and 75.4% respectively). The study of native samples is of little informative value (5.8%). The data obtained were used to develop an algorithm of microscopic investigation for the examination of patients with urogenital acute, subacute or chronic trichomoniasis and carriers of T. vaginalis.

[Frequency of curable sexually transmitted infections among registered female sex-workers in Ankara City]. / Ankara ilinde kayitli seks calisani kadinlarda iyilestirilebilir cinsel yolla bulasan enfeksiyonlarin sikligi.

Sex-workers are considered as the high-risk population for sexually transmitted infections (STIs). Early diagnosis and treatment of curable STIs in this high-risk group have crucial importance in STI control and prevention of complications and transmission of infection. In this study, 146 registered female sex-workers in Ankara city were screened with rapid diagnostic tests (RDT) for causative agents of curable STIs such as, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Treponema pallidum. To identify gonorrhoea, Gram stained endocervical smears were examined microscopically for the presence of gram-negative intracellular diplococci. For the diagnosis of chlamydial infection, an optic immunoassay (OIA) (Chlamydia OIA, Biostar, USA) as a RDT was performed by using endocervical specimens. For the detection of T. vaginalis, direct smears of vaginal swabs were examined for the presence of motile trophozoites first directly and after being cultured in Diamond's media for 24-48 hours of incubation. Syphilis was screened in the serum specimens by RPR (Omega, UK) test. There was no positive test results for gonorrhoea and syphilis however, the frequency of C. trachomatis and T. vaginalis in the study population was 1.4% and 0.7%, respectively. To provide comprehensive policies and optimal control strategies, a reliable source of data about the frequency and spectrum of STIs among high-risk populations and optimized effective screening programmes are required.

[Trichomoniasis].

Trichomonas vaginalis is the most common curable sexually transmitted disease worldwide. In spite of serious health sequelae including facilitation of HIV transmission, PID, and adverse outcomes of pregnancy, it remains an underestimated condition, as a half of female infections and the majority of male infections are asymptomatic. T. vaginalis infection was not restricted in high-risk groups, so screening or empiric treatment of low-risk groups should be considered. To develop diagnostic tests which is valuable like PCR and cheap like wet mount microscopy, and the targeted screening of asymptomatic patients will allow a large understanding of T. vaginalis epidemiology and raises concern about the impact of HIV transmission and female reproductive health. T. vaginalis can no longer be ignored.

Perinatal transmission of Trichomonas vaginalis: a case report.

BACKGROUND: Trichomonas vaginalis infection is associated with increased risks of adverse pregnancy outcome. Perinatal transmission of T vaginalis from an infected, untreated, pregnant woman to her female neonate can occur. CASE: A 22-year-old woman, gravida 3, para 2, with untreated trichomoniasis had an uncomplicated spontaneous vaginal delivery of a healthy female infant. At day of life 19 the newborn was diagnosed and treated for trichomoniasis. No evidence was found consistent with child sexual abuse. CONCLUSION: Perinatal transmission of T vaginalis occurs rarely. Neonatal infection has medical and psychosocial implications. This outcome, albeit rare, should be a consideration in the decision regarding antenatal treatment of T vaginalis infection.

Methods for detection of Trichomonas vaginalis in the male partners of infected women: implications for control of trichomoniasis.

Trichomonas vaginalis infection in men is an important cause of nongonococcal urethritis. Effective detection of the parasite in men using culture requires examination of multiple specimens. We compared culture and PCR-enzyme-linked immunosorbent assay in urethral swabs, urine, and semen for T. vaginalis detection in male sexual partners of women with trichomoniasis identified by wet mount and culture. Trichomonads were detected by at least one positive test in 205/280 men (73.2%) who submitted at least one specimen for culture and PCR. Whereas InPouch TV culture detected only 46/205 cases (22.5%), PCR detected 201/205 (98.0%). Urethral swab cultures from men with urethritis were more likely to be positive with shorter incubation than specimens from men without urethritis. T. vaginalis was detected more often in men with wet-mount-positive partners. Even with a sensitive PCR assay, reliable detection of T. vaginalis in male partners required multiple specimens. The majority of male sexual partners in this study were infected, emphasizing the importance of partner evaluation and treatment.