STI CASE MANAGEMENT : ACHIEVEMENTS AND CHALLENGES IN MOROCCO Aziza BENNANI National AIDS Program Manager

HIV Profile and Epidemiological Trend Low national prevalence : 0,11% Concentrated epidemic in some areas – FSW: Agadir – MM: Agadir, Marrakech – PWID : Nador, Tétouan notified cases ( ) Estimted PLHIV in % don’t know their status 86% Heterosexual Transmission 50% are female 1200 New infections/ year – 5 new infections/day – 4 AIDS realted deaths/ day 67% of new infections in key populations 70% of women are infected by their spouse MSM 3,7% MSM 4,4% MSM 4,2% MSM 5,7% PWID 7% PWID 13% FSW 1,7% FSW 5,1% FSW 1,4% Atlantic Ocean Mediterranean Sea Spain

STI Epidemiological trend Around new cases/ year Incidence stable, since 2000

Distribution of STI Syndroms STI Syndroms in Men STI Syndroms in Women

5 Background and Rational : STI Control within the National AIDS Program : Implementation of syndromic approach for STI case management – 3 Flowcharts: Uretral Discharge, Genital Ulcer, Vaginal Discharge and Lower Abdominal Pain – Surveillance system 2007: STI Prevalence Study in women complaining of vaginal discharge and lower abdominal pain Review of the national strategy and adoption of new flowcharts Training of Health Care Professionals 2009: STI Prevalence Study in men with uretral discharge and and NG resistance to antimicrobial Review of national treatment guidelines

6 Trois algorithmes adoptés PERTES VAGINALES ET/OU DOULEURS DU BAS VENTRE Algorithme

STI Prevalence in women (National Studies) 7 Prevalence study in women consulting for Vaginal Discharge and Lower Abdominal Pain MoH,2007 Women (general population) FSWsPrevalence study in women seeking FP and MCH srvices MoH, 1999 Prevalence study in women seeking FP and MCH srvices MoH, 2011 Sample size Bacterial Vaginosis8%17%14.2 % Trichomonas Vaginalis5%15%3 %5.4 % Neisseria Gonnorhoae (NG)1%7%0.9 %0.5 % Chlamydia Trachomatis (CT)6%19%4 %3.3 % Association (NG + CT)0,3%3,5%0.1 % Presence of STI12 %41 %8 %8 %8.8 % Serological Syphilis2.4 %13.8 %2.8 %2.2 %

STI Prevalence Study in Uretral Discharge and detection of Neisseria Gonorrheoae antimicrobial resistance Study Objectives – Determie STI prevalence in men complaining of UD, particularly Neisseria Gonorrhoeae and Chlamydia Trachomatis, – Determine the sensitivity of Neisseria gonorrhoeae isolated strains to antimicrobials and procced to treatment guidelines review Study Population: Men complaining of UD in PHC facilities Study Sample: 171 Study Sites: 5 Beni Mellal, Fes, Marrakesh, Rabat, Salé Results – Trichomonas Vaginalis (TV) in 4 % – 6 % in acute UD – Most of time associated to NG (6/7 cases) – Syphilis was found in 2.3 % of UD – No one was HIV positive

Study results: Prevalence of NG & CT (PCR) NG prevalence in UD : 63 % (Acute UD : 71%; Sub- acute UD: 49% ) CT prevlalence in UD: 10% (Sub acute UD: 17%; Acute UD: 8% ) NG+CT association in UD: 7% (Acute UD: 13 % ; Sub acute UD: 5%) No germ identified: 34 % (Sub acute: 47 %; Acute UD :26 % )

Resistance of NG to antimicriobials N = 68*SensitiveBorderlineResistant 2009Resistant Penicillin** Nombre % % 2. Ceftriaxone Nombre6800 % % 3. Erythromycine Nombre43241 % % 4. Ciprofloxacine Nombre6359 % % 5. Tetracycline Nombre3263 % % 6. Spectinomycine Nombre6800 % Cefotaxime Nombre6800 % * CMI was done on 68 strains (5 samples non received and 9 lost during storage) **27 cases no reported

STI Syndromic Management Flowcharts & Treatment guidelines 2012

STI syndroms 1.Uretral Discharge 2.Persistent or Reccurent UD 3.Genital Ulcer 4.Vaginal Discharge 5.Pelvic Inflammatory Disease (Lower Abdominal Pain) 6.Neonatal Conjonctivitis

2013: Surveillance and monitoring of NG resistance to antimicrobials (Mor - GASP) Sentinel surveillance system for NG resistance to antimicrobials, in 5 sites: Agadir, Fes, Beni Mellal, Oujda, Rabat – Samples were taken in PHC facilities and sent to the laboratory – 2 nd step 2 sites were added : Kenitra, Sidi Kacem – Samples were taken in the laboratory facilities – Close monitoring: weekly report was required from the sites Results: 36 GC strains, no one was resistant to cephalosporins 3 rd generation

Challenges Identification of prevalence of STI germs and adoption of the etiologic approach Lack of data concerning all STIs pathogens (HPV, HSV, Syphilis, …) Monitoring of resistance of NG and other STIs pathogens to antimicrobials Lack of data concerning syphilis in Pregnant women and congenital syphilis Lack of data related to the Neonatal conjonctivitis

Challenges Large proportion of self medication Missing patients to the notification system Lack of involvement of the private sector Notification and management of sexual partners Lack of specific strategy for STI case management in key populations (FSWs, MSM Lack of financiel resources

Main interventions in 2016 Point of care diagnosis and treatment: – HIV rapid test in VCT sites since 2004 – Syphilis rapid test will be implemented in HIV -VCT sites in 2016 the pilot experience of HIV community testing by lay providers will be expanded to thematic NGOs PrEP will be launched as pilot project with ALCS

Perspectives A sentinel system will set up once every two years Surveillance of syphilis in pregnant women in a combined program of elimination of congenital syphilis and HIV MTCT Specific flowcharts for STI case management in key populations (MSM & FSWs) Monitoring of NG resistance within the Mor- GASP Involvement of the private sector

Thank You