Research Article: Prevalence of sexually transmitted infections and bacterial vaginosis among women in sub-Saharan Africa: An individual participant data meta-analysis of 18 HIV prevention studies

Date Published: February 27, 2018

Publisher: Public Library of Science

Author(s): Elizabeth A. Torrone, Charles S. Morrison, Pai-Lien Chen, Cynthia Kwok, Suzanna C. Francis, Richard J. Hayes, Katharine J. Looker, Sheena McCormack, Nuala McGrath, Janneke H. H. M. van de Wijgert, Deborah Watson-Jones, Nicola Low, Sami L. Gottlieb, Peter Byass

Abstract: BackgroundEstimates of sexually transmitted infection (STI) prevalence are essential for efforts to prevent and control STIs. Few large STI prevalence studies exist, especially for low- and middle-income countries (LMICs). Our primary objective was to estimate the prevalence of chlamydia, gonorrhea, trichomoniasis, syphilis, herpes simplex virus type 2 (HSV-2), and bacterial vaginosis (BV) among women in sub-Saharan Africa by age, region, and population type.Methods and findingsWe analyzed individual-level data from 18 HIV prevention studies (cohort studies and randomized controlled trials; conducted during 1993–2011), representing >37,000 women, that tested participants for ≥1 selected STIs or BV at baseline. We used a 2-stage meta-analysis to combine data. After calculating the proportion of participants with each infection and standard error by study, we used a random-effects model to obtain a summary mean prevalence of each infection and 95% confidence interval (CI) across ages, regions, and population types. Despite substantial study heterogeneity for some STIs/populations, several patterns emerged. Across the three primary region/population groups (South Africa community-based, Southern/Eastern Africa community-based, and Eastern Africa higher-risk), prevalence was higher among 15–24-year-old than 25–49-year-old women for all STIs except HSV-2. In general, higher-risk populations had greater prevalence of gonorrhea and syphilis than clinic/community-based populations. For chlamydia, prevalence among 15–24-year-olds was 10.3% (95% CI: 7.4%, 14.1%; I2 = 75.7%) among women specifically recruited from higher-risk settings for HIV in Eastern Africa and was 15.1% (95% CI: 12.7%, 17.8%; I2 = 82.3%) in South African clinic/community-based populations. Among clinic/community-based populations, prevalence was generally greater in South Africa than in Southern/Eastern Africa for most STIs; for gonorrhea, prevalence among 15–24-year-olds was 4.6% (95% CI: 3.3%, 6.4%; I2 = 82.8%) in South Africa and was 1.7% (95% CI: 1.2%, 2.6%; I2 = 55.2%) in Southern/Eastern Africa. Across the three primary region/population groups, HSV-2 and BV prevalence was high among 25–49-year-olds (ranging from 70% to 83% and 33% to 44%, respectively). The main study limitation is that the data are not from random samples of the target populations.ConclusionsCombining data from 18 HIV prevention studies, our findings highlight important features of STI/BV epidemiology among sub-Saharan African women. This methodology can be used where routine STI surveillance is limited and offers a new approach to obtaining critical information on STI and BV prevalence in LMICs.

Partial Text: Sexually transmitted infections (STIs) and bacterial vaginosis (BV) are widespread globally. These conditions have important sexual, reproductive, and maternal-child health consequences, including genital symptoms, pregnancy complications, infertility, enhanced HIV transmission, and psychosocial effects. The World Health Organization (WHO) estimated that, in 2012, there were 357 million new episodes of 4 curable STIs (chlamydia, gonorrhea, syphilis, and trichomoniasis) [1] and 417 million people had infection with herpes simplex virus type 2 (HSV-2) [2]. Global estimates of BV occurrence are limited [3].

We followed a protocol and a prespecified analysis plan (S3 Text). We report our findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (S1 Text) and provide a checklist of items specific to IPD meta-analyses (S2 Text). PRISMA checklists for previous IPD analyses of these data are also available [6,34]. The US Centers for Disease Control and Prevention, WHO, and the Protection of Human Subjects Committee of FHI 360 determined that the research was exempt from ethical review. All included studies had relevant country-specific institutional ethical review and regulatory board approvals, and all participants within each study provided written informed consent for study participation. All principal investigators agreed to share their data for the present meta-analysis.

All 18 potentially eligible studies included testing for at least 1 STI and/or BV testing at baseline. Test technologies varied across studies (S2 Table). Five studies included multiple geographic regions and/or population types and were split into separate sub-studies for analysis, resulting in a total of 26 studies/sub-studies (hereafter referred to as “studies”) (Table 1). There were 10 studies in South Africa that were conducted among clinic/community-based populations (N = 9) and HIV-discordant couples (N = 1). Nine studies were conducted in Southern Africa (N = 5) or Eastern Africa (N = 4) among clinic/community-based populations (N = 7) and HIV-discordant couples (N = 2). Seven studies were conducted in Eastern Africa among higher-risk populations. Sample sizes of included studies ranged from 138 to 5,654.

In this IPD meta-analysis, we combined data from 18 prospective HIV prevention studies representing over 37,000 women in sub-Saharan Africa to estimate prevalence of chlamydia, gonorrhea, syphilis, trichomoniasis, HSV-2, and BV. We observed age-, region- and population-specific patterns in the prevalence of these infections, including higher prevalence of STIs among younger (15–24-year-old) than older (25–49-year-old) women, generally higher STI prevalence in clinic/community-based populations in South Africa than among similar populations elsewhere in Southern/Eastern Africa, and notably greater prevalence among higher-risk populations for certain STIs (e.g., gonorrhea and syphilis), but not for others (e.g., HSV-2 and BV, which had high prevalence across all population types).



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