HIV destigmatization: perspectives of people living with HIV in the Kumasi Metropolis in Ghana.

Background: Human immunodeficiency virus (HIV)-related stigma has been identified as one of the principal factors that undermines HIV prevention efforts and the quality of life of people living with HIV (PLWH) in many developing countries including Ghana. While studies have been conducted on HIV-related stigma reduction, very few have sought the views of PLWH on how this might be done. The purpose of the study was to (i) identify factors that cause HIV-related stigma in Ghana from the perspective of PLWH, (ii) identify challenges that HIV-related stigma poses to the treatment and care of PLWH, and (iii) to obtain recommendations from PLWH on what they think various groups (community members, health care providers, and adolescents) including themselves should do to help reduce HIV-related stigma in Ghana. Methods: A mixed methods cross-sectional study design was used to collect data from 404 PLWH at the Suntreso Government Hospital in the Kumasi Metropolis of Ghana across six domains using Qualtrics from November 1-30, 2022. Quantitative data was analyzed using the Statistical Package for Social Sciences (SPSS) version 26 and the Statistical Analysis System (SAS) version 9.4. Qualitative data was analyzed using a thematic approach. Results: Most of the study participants (70.5%) said HIV-related stigma in Ghana is due to ignorance. Of this population, 90.6% indicated that they had experienced stigma because they have HIV, causing them to feel depressed (2.5%), ashamed (2.2%), and hurt (3.0%). Study participants (92.8%) indicated that the challenges associated with HIV-related stigma has affected their treatment and care-seeking behaviors. Recommendations provided by study participants for HIV destigmatization include the need for PLWH not to disclose their status (cited 94 times), community members to educate themselves about HIV (96.5%), health care providers to identify their stigmatizing behaviors (95.3%), health care providers to avoid discriminating against PLWH (96.0%), and the need for adolescents to be educated on HIV and how it is transmitted (97.0%). Conclusion: It is important for the government and HIV prevention agencies in Ghana to target and address co-occurring HIV-related stigma sources at various levels of intersection simultaneously This will help to shift harmful attitudes and behaviors that compromise the health and wellbeing of PLWH effectively.

HIV status disclosure and sexual activity among pregnant women in Ghana.

Human Human immunodeficiency virus (HIV) status disclosure to sexual partners is associated with prevention, care, treatment, and support for pregnant women with HIV. We aimed to assess HIV status disclosure and sexual activity among pregnant women with HIV. We conducted a cross-sectional hospital-based survey using quantitative methods. Data were collected from 118 pregnant women with HIV enrolled in the prevention of mother-to-child transmission (PMTCT) program from January to November 2019. Sixty-seven percent (67%) of these pregnant women did not know they had HIV until they were tested in the routine antenatal HIV testing program. HIV status nondisclosure rate was 62.7%, and the most common reason for nondisclosure was fear of loss of financial support (41.9%). Higher parity was associated with lower odds of disclosing HIV status (aOR = 0.36; p < 0.01). Sexual activity with partners and condom use were associated with HIV disclosure (ps < 0.01). Pregnant women who disclosed their HIV status to their partners were sexually active with them (37.3%), and all those who did not but were sexually active with their partners did not use condoms (36.2%) during the pregnancy. Our findings emphasize the need for interventions that encourage HIV status disclosure and affirm the importance of routine HIV testing for pregnant women.

Self-Medication and Antimicrobial Resistance: A Survey of Students Studying Healthcare Programmes at a Tertiary Institution in Ghana.

Objectives: Antimicrobial resistance (AMR) is one of the biggest challenges facing mankind. Inappropriate uses of antibiotics including self-medication promote the increase and spread of AMR. Self-medication has not been well-studied among students. This study was undertaken to determine students of healthcare programmes self-medication practices and attitudes in relation to AMR. Materials and Methods: This was a cross-sectional survey that used a pretested self-administered questionnaire to elicit responses from first-year students of healthcare programmes at the Kwame Nkrumah University of Science and Technology, Ghana from January 2018 to August 2019. Results: Two hundred and eighty students were recruited with 264 of them returning the questionnaire, giving a response rate of 94.3%. Majority were female (68.9%) and participants ages ranged from 16 to 34 years with a mean age (SD) of 19.5 (1.88) years. 136 students (56.2%) had previously purchased antibiotics without a prescription and 78.3% expressed satisfaction with the outcome of self-medication. Amoxicillin (78%) was the most frequent antibiotic bought without a prescription. Majority (76.3%) agreed that self-medication can lead to AMR. Majority (77.0%) believed that antibiotic abuse is a problem in Ghana and 94.8% agreed that the introduction of a course in the University on the rational use of antibiotic will help improve student's knowledge and practices. Conclusion: Self-medication is common among participants despite their knowledge that inappropriate use of antibiotic may lead to resistance. Innovative ways including the introduction of new curricula may help to improve knowledge and to curb wrong attitudes and practices related to antibiotic misuse and ultimately to overcome the problem of AMR.

High levels of used syringe use and unsafe sex among people who inject drugs in Kumasi, Ghana: an urgent call for a comprehensive harm reduction approach.

BACKGROUND: Drug use is a growing concern in Ghana. People who inject drugs (PWID) are highly vulnerable to HIV and other infectious diseases. Ghana's National Strategic Plan for HIV/AIDS 2016-2020 identifies PWID as a key population, but efforts to address the needs of PWID have lagged behind those targeting sex workers and men who have sex with men. Lack of information about PWID is a critical barrier to implementing effective HIV prevention and treatment. We aimed to learn more about the vulnerability of the PWID population in order to inform much-needed harm reduction interventions. METHODS: From April to July 2018, we conducted a mixed methods study in Kumasi, Ghana, to identify all major drug using locations, count the numbers of PWID to obtain rough population size estimations, and administer anonymous surveys to 221 PWID regarding drug use and sexual behavior. We also tested for HIV, HCV, and HBV from syringes used by survey participants. RESULTS: Key informants identified five major drug using locations and estimated the total PWID population size to be between 600 and 2000. Enumerators counted between 35 and 61 individuals present at each of the five bases. Sharing syringes and reusing discarded syringes are common practices. Over half of survey participants (59%) reported past-month syringe sharing (34% used a used syringe and 52% gave away a used syringe). Individuals with higher injection frequency (≥ 21 times weekly) and who injected with four or more people had higher odds of syringe sharing. Of the survey participants reporting sex in the last month (23%), most reported having one partner, but only 12% used condoms. Nearly all women (11/13) reported exchanging sex for drugs and 6/13 reported exchanging sex for money in the last six months. Fifteen percent of participants (all men) reported paying for sex using drugs or money. Of the used syringes, prevalence estimates were 3% (HIV), 2% (HCV), and 9% (HBV). CONCLUSIONS: Our findings confirm the urgent need to implement harm reduction interventions targeting PWID and to build a strong and enabling legal and policy environment in Ghana to support these efforts.

Autonomy-Supportive Healthcare Climate and HIV-Related Stigma Predict Linkage to HIV Care in Men Who Have Sex With Men in Ghana, West Africa.

In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM (N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate (OR = 1.63, p < .01), vicarious HIV stigma (OR = 2.73, p < .01), and age (OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC (OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.

Love, power, resilience and vulnerability: relationship dynamics between female sex workers in Ghana and their intimate partners.

Little is known about female sex workers' daily lives or emotional relationships. Using relational-cultural theory, this study explored the relationship dynamics between sex workers and their intimate partners in Kumasi, Ghana. We collected qualitative data from 37 male intimate partners through 24 in-depth interviews and two focus group discussions (FGDs) with 13 male partners. We also conducted three FGDs with 20 women involved in sex work. Relationships between sex workers and their intimate partners were mutual, reciprocal and transactional. Male partners provided protection for financial support, a place to sleep and intimacy. Both men and women described their relationships in terms of friendship, love and a hopeful future. Women were reluctant to quit sex work because they depended on it for income. Most respondents did not use condoms in these romantic relationships, citing trust, love, faithfulness and commitment. Both men and women described high levels of violence in their relationships. The context of sex work heightens vulnerability but also appears to facilitate resilience and creative coping strategies. The relational dynamics between sex workers and their intimate partners in Ghana merit further exploration to examine the extent to which women involved in sex work hold and exert power within these relationships.

"Too Much Sex and Alcohol": Beliefs, Attitudes, and Behaviors of Male Adolescents and Young Men Who have Sex with Men in Ghana.

BACKGROUND: Research suggests that men who have sex with men (MSM) often engage in high-risk sex and use illicit substances. OBJECTIVE: To increase understanding of HIV knowledge and vulnerability among adolescent and young adult MSM, with a focus on alcohol and drug use and transactional sex. METHODS: We conducted in-depth interviews and Focus Group Discussions (FGDs) with adolescent (aged 15-17 years) and young adult (aged 18-29 years) MSM in Kumasi, Ghana. MSM who reported recent alcohol and/or substance use or engagement in transactional sex were eligible. Questions covered HIV-related knowledge, experiences with substance-use and transactional sex, and attitudes regarding sexual risk-taking and HIV-related services. Data were analyzed thematically using NVivo 10.0 software. RESULTS: Ninety-nine MSM participated in 44 interviews and 8 FGDs. Most were attending or had completed secondary school. HIV knowledge was high, but with major gaps. Most consumed alcohol; one-fourth used drugs. Alcohol and substances were consumed to enhance pleasure during sex with another man. Transactional sex was common and positively viewed. Half of the participants used condoms inconsistently or never, and self-perceived HIV risk was high. Nearly half faced stigma-related barriers to accessing HIV-related services. CONCLUSION: As Ghana strives to achieve the UNAIDS's 90-90-90 global targets (90% of people living with HIV know their status, 90% who know their status are on sustained treatment, and 90% of those on treatment are virally suppressed), we recommend enhancing MSM-targeted prevention programs, improving care options, and increasing use of critical clinical HIV-services by ensuring that MSM receive unbiased, confidential care.

Tenofovir-Based Highly Active Antiretroviral Therapy Is Associated with Superior CD4 T Cells Repopulation Compared to Zidovudine-Based HAART in HIV 1 Infected Adults.

Tenofovir-based highly active antiretroviral therapy (HAART) is one of the preferred first-line therapies in the management of HIV 1 infection. Ghana has since 2014 adopted this recommendation; however there is paucity of scientific data that reflects the safety and efficacy of the tenofovir-based therapy compared to zidovudine in the Ghanaian health system. This study sought to assess the comparative immune reconstitution potential between tenofovir and zidovudine-based HAART regimens, which includes lamivudine and efavirenz in combination therapy. It also aimed to investigate the adverse drug reactions/events (ADREs) associated with pharmacotherapy with these agents in a total of 106 HAART naïve HIV patients. The study included 80 patients in the tenofovir cohort while 26 patients were on the zidovudine regimen. The occurrence of HIV comorbidities profile was assessed at diagnosis and throughout the study period. The baseline CD4 T cells count of the participants was also assessed at diagnosis and repeated at a median period of five months (range 4-6 months), after commencing treatment with either tenofovir- or zidovudine-based HAART. After five months of the HAART, the tenofovir cohort recorded higher CD4 T cell count change from baseline compared to the zidovudine cohort (p < 0.0001). The patients on the tenofovir-based HAART and female sex however appeared to be associated with more multiple ADREs.

"But the moment they find out that you are MSM ": a qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana's health care system.

BACKGROUND: The prevalence of HIV in Ghana is 1.3%, compared to 17% among men who have sex with men (MSM). There is limited empirical data on the current health care climate and its impact on HIV prevention services for Ghanaian MSM. The purposes of this study were to investigate (1) MSM's experiences using HIV prevention resources, (2) what factors, including health care climate factors, influenced MSM's use of prevention resources and (3) MSM self-identified strategies for improving HIV/sexually transmitted infection (STI) prevention among MSM in Ghanaian communities. METHODS: We conducted 22 focus groups (n = 137) with peer social networks of MSM drawn from three geographic communities in Ghana (Accra, Kumasi, Manya Krobo). The data were examined using qualitative content analysis. Interviews with individual health care providers were also conducted to supplement the analysis of focus group findings to provide more nuanced illuminations of the experiences reported by MSM. RESULTS: There were four major findings related to MSM experiences using HIV prevention resources: (1) condom quality is low, condom access is poor, and condom use is disruptive, (2) inaccurate information undermines HIV testing (3), stigma undermines HIV testing, and (4) positive attitudes towards HIV prevention exist among MSM. The main healthcare climate factors that affected prevention were that MSM were not free to be themselves, MSM were not understood by healthcare providers, and that MSM did not feel that healthcare providers cared about them. To improve HIV prevention MSM suggested increased education tailored to MSM should be provided to enable self-advocacy and that education and awareness are needed to protect human rights of MSM in Ghana. CONCLUSION: MSM in Ghana are exposed to negative health care climates. Health care spaces that are unsupportive of MSM's autonomy undermine the uptake of prevention measures such as condoms, HIV testing, and accurate sexual health education. These findings contribute to knowledge to inform development of HIV prevention interventions for MSM in Ghana, such as culturally appropriate sexual health education, and digital technology to connect individuals with resources supportive of MSM.

Bacterial etiology of sexually transmitted infections at a STI clinic in Ghana; use of multiplex real time PCR.

BACKGROUND: Most sexually transmitted infection (STI) management efforts focus on the syndromic approach to diagnose and treat patients. However, most women with STIs have been shown to be entirely asymptomatic, or if symptoms exist, are often missed when either clinical or conventional bacteriologic diagnostic tools are employed. METHODS: We assessed the performance of a multiplex real time PCR assay to describe other potential pathogens that could be missed by conventional bacteriological techniques in 200 women attending a routine STI clinic in Kumasi, Ghana. RESULTS: Although a total 78.00% of the women were asymptomatic, 77.1% of them tested positive for at least one bacterial STI pathogen. Mycoplasma genitalium was the most commonly detectable pathogen present in 67.5% of all women. Of those testing positive, 25.0% had single infections, while 38.0% and 19.5% had double and triple infections respectively. Altogether, 86.54% and 90.91% of the symptomatic and asymptomatic women respectively tested positive for at least one pathogen (p<0.05). There were no significant associations (p<0.05) between the clinical manifestations of the symptomatic women and the pathogens detected in their samples. CONCLUSIONS: Our study confirmed the importance of complementing the syndromic approach to STI management with pathogen detection and most importantly recognise that STIs in women are asymptomatic and regular empirical testing even for both symptomatic and asymptomatic patients is critical for complete clinical treatment. FUNDING: EOD (Ellis Owusu-Dabo Research working group, KCCR).

Cost effectiveness of option B plus for prevention of mother-to-child transmission of HIV in resource-limited countries: evidence from Kumasi, Ghana.

BACKGROUND: Achieving the goal of eliminating mother-to-child HIV transmission (MTCT) necessitates increased access to antiretroviral therapy (ART) for HIV-infected pregnant women. Option B provides ART through pregnancy and breastfeeding, whereas Option B+ recommends continuous ART regardless of CD4 count, thus potentially reducing MTCT during future pregnancies. Our objective was to compare maternal and pediatric health outcomes and cost-effectiveness of Option B+ versus Option B in Ghana. METHODS: A decision-analytic model was developed to simulate HIV progression in mothers and transmission (in utero, during birth, or through breastfeeding) to current and all future children. Clinical parameters, including antenatal care access and fertility rates, were estimated from a retrospective review of 817 medical records at two hospitals in Ghana. Additional parameters were obtained from published literature. Modeled outcomes include HIV infections averted among newborn children, quality-adjusted life-years (QALYs), and cost-effectiveness ratios. RESULTS: HIV-infected women in Ghana have a lifetime average of 2.3 children (SD 1.3). Projected maternal life expectancy under Option B+ is 16.1 years, versus 16.0 years with Option B, yielding a gain of 0.1 maternal QALYs and 3.2 additional QALYs per child. Despite higher initial ART costs, Option B+ costs $785/QALY gained, a value considered very cost-effective by World Health Organization benchmarks. Widespread implementation of Option B+ in Ghana could theoretically prevent up to 668 HIV infections among children annually. Cost-effectiveness estimates remained favorable over robust sensitivity analyses. CONCLUSIONS: Although more expensive than Option B, Option B+ substantially reduces MTCT in future pregnancies, increases both maternal and pediatric QALYs, and is a cost-effective use of limited resources in Ghana.

The Association of HIV Stigma and HIV/STD Knowledge With Sexual Risk Behaviors Among Adolescent and Adult Men Who Have Sex With Men in Ghana, West Africa.

Ghanaian men who have sex with men (MSM) have a high HIV seroprevalence, but despite a critical need to address this public health concern, research evidence has been extremely limited on influences on sexual risk behavior among MSM in Ghana. To investigate associations between HIV/STD knowledge, HIV stigma, and sexual behaviors in a sample of MSM in Ghana, we conducted a secondary data analysis of cross-sectional survey data from a non-probability sample of Ghanaian MSM (N = 137). Nearly all the men (93%) had more than one current sex partner (M = 5.11, SD = 7.4). Of those reported partners, the average number of current female sexual partners was 1.1 (SD = 2.6). Overall, knowledge levels about HIV and STDs were low, and HIV stigma was high. There was no age-related difference in HIV stigma. Younger MSM (≤25 years) used condoms less often for anal and vaginal sex than did those over 25. Relative frequency of condom use for oral sex was lower in younger men who had higher STD knowledge and also was lower in older men who reported high HIV stigma. Knowledge and stigma were not associated with condom use for anal or vaginal sex in either age group. These descriptive data highlight the need for the development of intervention programs that address HIV/STD prevention knowledge gaps and reduce HIV stigma in Ghanaian communities. Intervention research in Ghana should address age-group-specific HIV prevention needs of MSM youth.

Drug use and sexual behavior: the multiple HIV vulnerabilities of men and women who inject drugs in Kumasi, Ghana.

BACKGROUND: Recent evidence suggests that injecting drug use presents a new challenge to HIV prevention in West Africa. Very little is known about the HIV vulnerability of people who inject drugs (PWID) in Ghana, and no HIV prevention efforts are currently targeting PWID. METHODS: Purposive sampling was used to recruit 30 (20 men and 10 women) PWID to participate in in-depth interviews in Kumasi, Ghana. Transcripts were coded and analyzed by theme. RESULTS: Half the men and more than half the women in this study reported sharing needles/syringes (N/S); most shared a common mixing container; and all said they shared N/S with intimate partners. Some PWID who said that they do not share N/S with other PWID, also said they routinely use N/S that they find on the ground at injecting sites or in the hospital dumpster. Nearly, all the women (9/10) and more than half the men (12/20) were currently sexually active; most had more than 1 partner in the last 6 months, but very few reported condom use. Three women said they exchanged sex for money and 3 men reported buying sex in the last year. Several PWID had no knowledge of HIV transmission through injecting. CONCLUSIONS: PWID in Kumasi are highly vulnerable to HIV because of N/S sharing and reuse, lack of condom use, low knowledge of HIV transmission, and lack of services. Program and policy recommendations include N/S and condom distribution, peer education, opioid substitution therapy, and training of health providers, police, and pharmacy staff.

"It's all about making a life": poverty, HIV, violence, and other vulnerabilities faced by young female sex workers in Kumasi, Ghana.

OBJECTIVES: This study aimed to identify social, economic, structural, and individual-level vulnerabilities of female adolescents who sell sex in Kumasi, Ghana. METHODS: Twenty-four in-depth interviews and 4 focus group discussions were conducted with female sex workers of age 18-20 years who had been involved in sex work for at least 2 years. Total sample size was 48. FINDINGS: One-third of participants started sex work before age 15. Knowledge of HIV was accurate and most reported having intentions to use condoms consistently with clients; however, factors such as higher payments, drug and/or alcohol use, fear of violence, and police harassment affected condom use. They perceived violence and rape at the hands of clients as their greatest risk. They also reported abuse and exploitation by police. Respondents voiced strong concerns that girls and teens involved in sex work are at higher risk of unsafe sex, exploitation, and abuse than their older and more experienced counterparts. Unprotected sex with boyfriends was also common. DISCUSSION: The pathway to sex work followed a similar pattern for many study participants who left their rural homes for Kumasi in search of economic opportunity. While adolescents who sell sex appear to be abundant in Kumasi, they have been missed by HIV prevention and harm reduction programming. The findings from this study informed the design and implementation of a young female sex worker peer educator pilot program. Key elements of that program are presented, and recommendations for future program evaluation are made.

Predictors of condom use among peer social networks of men who have sex with men in Ghana, West Africa.

Ghanaian men who have sex with men (MSM) have high rates of HIV infection. A first step in designing culturally relevant prevention interventions for MSM in Ghana is to understand the influence that peer social networks have on their attitudes and behaviors. We aimed to examine whether, in a sample of Ghanaian MSM, mean scores on psychosocial variables theorized to influence HIV/STI risk differed between peer social networks and to examine whether these variables were associated with condom use. We conducted a formative, cross-sectional survey with 22 peer social networks of MSM (n = 137) in Ghana. We assessed basic psychological-needs satisfaction, HIV/STI knowledge, sense of community, HIV and gender non-conformity stigmas, gender equitable norms, sexual behavior and condom use. Data were analyzed using analysis of variance, generalized estimating equations, and Wilcoxon two sample tests. All models were adjusted for age and income, ethnicity, education, housing and community of residence. Mean scores for all psychosocial variables differed significantly by social network. Men who reported experiencing more autonomy support by their healthcare providers had higher odds of condom use for anal (AOR = 3.29, p<0.01), oral (AOR = 5.06, p<0.01) and vaginal (AOR = 1.8, p<0.05) sex. Those with a stronger sense of community also had higher odds of condom use for anal sex (AOR = 1.26, p<0.001). Compared to networks with low prevalence of consistent condom users, networks with higher prevalence of consistent condom users had higher STD and HIV knowledge, had norms that were more supportive of gender equity, and experienced more autonomy support in their healthcare encounters. Healthcare providers and peer social networks can have an important influence on safer-sex behaviors in Ghanaian MSM. More research with Ghanaian MSM is needed that considers knowledge, attitudes, and norms of their social networks in the development and implementation of culturally relevant HIV/STI prevention intervention strategies.

The syndromic management of vaginal discharge using single-dose treatments: a randomized controlled trial in West Africa.

OBJECTIVE: To evaluate whether single-dose treatments are as effective as standard therapy in the syndromic management of vaginal discharge. METHODS: A randomized controlled effectiveness trial compared single-dose tinidazole plus fluconazole (TF) with treatment for 7 days with metronidazole plus 3 days of treatment with vaginal clotrimazole (MC) among 1570 women presenting with vaginal discharge at primary health care institutions in Ghana, Guinea, Mali and Togo. Participants were randomly allocated to one of the two treatments by research nurses or physicians using precoded envelopes. Effectiveness was assessed by symptomatic response on day 14. CLINICAL IDENTIFIER ClinicalTrials.gov NCT00313131. FINDINGS: The two treatment regimens had similar effectiveness: complete resolution was seen in 66% (TF) and 64% (MC) and partial resolution in 33% (TF) and 34% (MC) of participants (P = 0.26). Effectiveness was similar among subgroups with vulvovaginal candidiasis, Trichomonas vaginalis vaginitis or bacterial vaginosis. The two treatment regimens had a similar effectiveness among human immunodeficiency virus (HIV)-infected (TF: n = 76, 71% complete resolution, 28% partial; MC: n = 83, 72% complete resolution, 25% partial, P = 0.76) and HIV-uninfected women (TF: n = 517, 68% complete, 32% partial; MC: n = 466, 65% complete, 33% partial, P = 0.20). Cervical infections with Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium were uncommon among women not involved in sex work, were associated with bacterial vaginosis or T. vaginalis vaginitis, and did not alter response to treatment with agents active against vaginal infections. Four-fifths of women not relieved by a single dose of TF had a favourable response when MC was administered as second-line treatment. CONCLUSION: Single-dose TF is as effective as multiple-dose MC in the syndromic management of vaginal discharge, even among women with HIV-infection. Given its low price and easier adherence, TF should be considered as a first-line treatment for vaginal discharge syndrome.