STIs and HIV in South Africa
In South Africa, a country that has battled with the HIV and TB co- epidemic for more than two decades, STI management has received little attention. We were delighted to read the article by Lurie et al, which highlights the high burden of STI syndromes in people living with HIV, in particular, in the period before ART initiation. While we concur with the authors' conclusions that systematic STI testing and treatment is warranted in HIV care programmes, the epidemiological data presented leave several unanswered questions.
There are major problems with reliance on syndromic management, particularly with the syndrome of vaginal discharge. STI symptoms poorly correlate with laboratory diagnoses, illustrated by gonorrhoea and chlamydia, which are mostly asymptomatic in women. Studies at the Centre for the AIDS Programme of Research in South Africa (CAPRISA) have shown a high prevalence of laboratory-diagnosed STIs in women at the time of acute HIV infection. Further analysis showed that clinical assessment alone missed 88% of laboratory-diagnosed STIs and 66% received unnecessary treatment .
Furthermore, the commonest cause of vaginal discharge is bacterial vaginosis (BV), an infection that is associated with sex, but does not appear to be sexually transmitted. We have found that over 50% of women had BV at HIV diagnosis which is often persistent . Lurie et al omit mentioning BV, perhaps misclassifying some of their findings.
While the authors' results are intriguing, a potential mechanism for the reduction of syndromic STIs on ART is missing. One could hypothesize that immunosuppression may increase the susceptibility and ability to clear STIs and BV. However, in this study the reduction in incidence was independent of CD4 count, in fact, the opposite was true, that a higher CD4 count was associated with more syndromic STI diagnoses. Alternative mechanisms namely behavioural change and length of clinical follow-up may have had a greater impact on the reduction of syndromic STI incidence than improvement in CD4 count in response to ART.
We hope, that the findings by Lurie et al and the following debate will contribute to the long overdue implementation of STI testing and treatment policies in South Africa.
Nigel Garrett and Adrian Mindel Centre for the AIDS Programme of Research in South Africa (CAPRISA)
1.Mlisana K, Naicker N, Werner L, Roberts L, van Loggerenberg F, Baxter C, et al. Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections and genital tract inflammation in high- risk women in South Africa. J Infect Dis 2012,206:6-14.
Conflict of Interest: