2. Human Immunodeficiency Virus Infection among Patients with Sexually Transmitted Infections in Zimbabwe: 2014-2015 More Mungati: MBChB, MPH Zimbabwe Ministry of Health and Child Care University of Zimbabwe, Department of Community Medicine

3. Sexually Transmitted Infections (STIs), an HIV time-bomb OCTOBER 19, 2014 “We are concerned about the rise in STIs as a ministry. We are wondering if people are taking the necessary precautions to protect themselves against sexually transmitted diseases or is there a relapse in behaviour change. Despite the gains we have made so far in fighting HIV, the rise in STIs might mean that we are going back to an era when HIV was rife.” 3

4. Introduction Sexually Transmitted Infections (STIs) remain diseases of public health importance Syndromic approach used in Zimbabwe Surveillance informs public health action STIs are co-factors in HIV transmission Presence may be a marker of transmission risk Knowledge on co-occurrence informs prevention 4

5. Introduction What are the causes of STI syndromes in Zimbabwe? What is the prevalence of HIV among these syndromes? 5

6. Introduction To assess the prevalence of HIV among patients presenting with sexually transmitted syndromes in Zimbabwe 6

7. Methods Study Design:- Analytic cross sectional Study Population -Men with urethral discharge (n=200) -Women with vaginal discharge (n=200) -Men or women with genital ulcer disease (GUD; n=200) Study Setting -Harare: Mbare and Budiriro -Bulawayo: Khami Road Clinic and Nkulumane Polyclinic -Beitbridge: Dulibadzimu Clinic -Gutu: Gutu Rural Hospital 7

8. Gutu 8

9. Methods Data Collection Interviewer administered questionnaire Clinical examination Sample collection Data Analysis SAS Permission and Ethical Considerations Written informed consent Ethical review by Ministry of Health and Child Care, Medical Research Council of Zimbabwe, Research Council of Zimbabwe and Centers for Disease Control and Prevention, Atlanta 9

10. Methods Laboratory Testing Samples from genital discharge for Gram-staining -Men: urethritis -Women: bacterial vaginosis and yeast infections Blood samples -HIV testing: First Response; Determine; Chembio -Treponemal (SD-DUO rapid) and non-treponemal serology (RPR) 10

11. Methods Nucleic acid amplification tests (NAAT) for: Genital discharge : N. gonorrhoeae (NG): Probetec; Gene Xpert, M-PCR C. trachomatis (CT): Probetec, Gene Xpert, M-PCR M. genitalium (MG): M-PCR T. vaginalis (TV): M-PCR Genital ulcers : T. pallidum (TP): M-PCR H. ducreyi (HD): M-PCR C. trachomatis (LGV): M-PCR Herpes simplex virus (HSV): M-PCR 11

12. Results 12

13. Results Recruitment rate 100% (N=600) HIV testing was accepted by 492 (82%) Of these 492 the following were available for analysis: -Treponemal testing: n=492 -Non-treponemal testing (RPR): n=492 -Probetec CT/NG: n=491 -Gene Xpert CT/NG: n=466 -M-PCR Discharge: CT/NG/MG/TV: n=311 -M-PCR GUD: TP/HD/CT-LGV/HSV: n=181 13

14. Results 14

15. Results 15

16. STIs Among Patients by HIV Status, Zimbabwe 16

17. Syphilis and Genital Herpes among GUD Patients by HIV Status (n=182) 17

18. Factors Associated with HIV Infection Among Men and Women with STI Syndromes, Zimbabwe: 2014-15 18 FactoraOR95% C.I. Gonorrhoea1.91.2-3.1 Chlamydia0.50.3-0.9 Syphilis (N) TP 1 1.81.1-3.1 Female GUD 2,4 4.42.3-8.1 Male GUD 2,4 2.51.3-4.6 Female GDS 3,4 2.11.2-3.5 1 Syphilis (N) TP: any RPR or Duo positive test 2 GUD: Genital Ulcer Disease 3 GDS: Genital Discharge Disease 4 Female GUD, Male GUD and Female GDS compared to Male GDS as referent

19. HIV Result by Self-Reported HIV Status, Zimbabwe: 2014-15 19

20. Discussion HIV prevalence was >30% in all syndromes Presence of ulcer potentiates HIV transmission Positive associations between HIV prevalence and STIs Causal link between HIV and STIs HIV found among STI patients with unknown status May be due to reluctance to disclose HIV status 20

21. Discussion The association between HIV and incident gonorrhea and syphilis indicates: High risk sexual behaviors leading to both HIV and other STIs High risk of ongoing HIV transmission among those with pre- existent HIV infection and new STI infections Patients with STIs should be a major focus of HIV prevention efforts 21

22. Limitations Only patients with symptomatic STIs studied Possible over-sampling of high risk patients 22

23. Conclusion Patients with STIs symptoms are in response to HIV Should be a major focus for effort 23

24. Thank You 24