|Year : 2016 | Volume
| Issue : 3 | Page : 322-326
Routine screening for Trichomonas vaginalis among human immunodeficiency virus-seropositive antenatal clients in Zaria: A necessity or option?
N Isaac1, PI Onwuhafua1, AO Oguntayo1, AS Opaluwa2
1 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
2 Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
|Date of Web Publication||8-Feb-2017|
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna
Source of Support: None, Conflict of Interest: None
Background: Trichomonas vaginalis infection is the most common curable sexually transmitted infection worldwide with about 160–180 million people affected annually. Pregnant women with trichomoniasis are at a risk of adverse pregnancy outcomes such as premature rupture of membranes, preterm labor, low birth weight as well as neonatal infection with human immunodeficiency virus (HIV), and T. vaginalis. There is a paucity of knowledge of prevalence of T. vaginalis infection among HIV-seropositive antenatal clinic attendees in northwestern Nigeria.
Objectives: The objective of this study was to determine the prevalence of T. vaginalis vaginitis among HIV-seropositive antenatal clinic clients in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria.
Design: The study was a descriptive cross-sectional study.
Setting: The study was conducted at the Antenatal/Prevention of Mother to Child Transmission clinic of ABUTH, Zaria, between May 6 and September 5, 2013.
Materials and Methods: One hundred and two HIV-seropositive pregnant women were recruited into the study. Sociodemographic, clinical, and obstetric information were obtained using a pro forma. Vaginal swabs were collected from each woman and examined using wet mount microscopy for T. vaginalis and cultivated in Trichomonas OXOID culture media enriched with horse sera. Results were analyzed with SPSS software Version 16.
Results: The mean age of the participants was 31 years with a standard deviation of 4.9 years. Out of the 102 participants examined for T. vaginalis, 6 were positive using both wet mount microscopy and culture giving a prevalence rate of 5.9% and about 60% of the positive clients were symptomatic.
Conclusion: The prevalence of T. vaginalis vaginitis among HIV antenatal clinic attendees in ABUTH, Zaria, was 5.9%. About 40% of the trichomonad-positive participants were asymptomatic. Routine screening of HIV-seropositive antenatal clients for T. vaginalis is cost-effective.
Keywords: Antenatal; human immunodeficiency virus; routine screening; Trichomonas vaginalis.
|How to cite this article:|
Isaac N, Onwuhafua P I, Oguntayo A O, Opaluwa A S. Routine screening for Trichomonas vaginalis among human immunodeficiency virus-seropositive antenatal clients in Zaria: A necessity or option?. Trop J Obstet Gynaecol 2016;33:322-6
|How to cite this URL:|
Isaac N, Onwuhafua P I, Oguntayo A O, Opaluwa A S. Routine screening for Trichomonas vaginalis among human immunodeficiency virus-seropositive antenatal clients in Zaria: A necessity or option?. Trop J Obstet Gynaecol [serial online] 2016 [cited 2020 Mar 31];33:322-6. Available from: http://www.tjogonline.com/text.asp?2016/33/3/322/199816
| Introduction|| |
Trichomonas vaginalis, an anaerobic, parasitic, flagellated protozoon is the causative agent of trichomoniasis and is the most prevalent nonviral, sexually transmitted infection (STI) worldwide, with an estimated 180 million infections acquired annually. Humans are the only known host with the trophozoites transmitted principally through vaginal sexual intercourse and rarely through formites.
Trichomonas infection ranges from an asymptomatic carrier state to a profound acute inflammatory disease.T. vaginalis has been implicated in upper reproductive tract infections, postsurgical infections, reversible infertility, preterm labor, low birth weight, neonatal morbidity and mortality. It is estimated that 2%–17% of female infants acquire T. vaginalis through direct vulvo-vaginal contamination. It has also been incriminated as a cofactor in the transmission of human immunodeficiency virus (HIV).
T. vaginalis has neither been the focus of intensive study nor of active control program in sub-Saharan Africa, and this neglect is likely a function of the relative mild nature of the disease. However, available evidence suggests that T. vaginalis may play a critical and under-recognized role in amplifying HIV transmission and in some circumstances may have a major impact on the epidemic dynamics of HIV infection and acquired immunodeficiency syndrome in sub-Saharan Africa.,
The possible mechanisms include infection with T. vaginalis that results in an inflammatory response, leading to recruitment of CD4 lymphocytes and macrophages to the vaginal and cervical mucosa. Second, T. vaginalis has a direct cytopathic effect in vitro, resulting in microhemorrhages potentially compromising the mechanical barrier to HIV transmission. Third, T. vaginalis has been shown to be associated with increased viral load in the cervico-vaginal compartment. Finally, some studies have shown that T. vaginalis increases susceptibility to bacterial vaginosis or colonization with other abnormal vaginal flora which in turn could increase the risk of HIV acquisition.
In the United States, it is estimated that 747 new HIV cases a year in pregnant women alone are as a result of the facilitative effect of T. vaginalis on the transmission of HIV with a significantly higher number of HIV RNA particles in the body fluid of women infected with T. vaginalis. On the other hand, treatment of trichomoniasis resulted in a 4.2-fold reduction in the number of HIV particles in the vaginal specimen.
T. vaginalis infection has in the past been considered a “nuisance” disease of women and a problem of developing countries. However, increasing global infection rates, pregnancy complications, and increased susceptibility to HIV and other sexually transmitted diseases make it clear that safe, effective, and affordable treatment of trichomoniasis is essential.
Poor knowledge of the hazards of T. vaginalis vaginitis among HIV-seropositive clients is an important factor in the spread of the infection in Zaria. Other reasons include poverty and cultural practices. It is thus essential to study trichomoniasis among HIV-seropositive antenatal clients with a view to providing information and database for control of the spread of the infection.
| Materials and Methods|| |
The study was a descriptive cross-sectional study and was carried out at the Antenatal/Prevention of Mother to Child Transmission (PMTCT) clinic of Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. The study protocol was approved by ABUTH Ethical Committee in Zaria. Eligible participants were HIV-seropositive women attending the antenatal/PMTCT clinic.
Preparation of culture media
Exactly 37.5 g of Trichomonas medium base was suspended in 1 L of distilled water and brought to boil to dissolve. It was sterilized by autoclaving at 121°C for 15 min and then cooled to approximately 50°C. Eighty milliliters of horse serum was inactivated by heating and maintaining at a temperature of 56°C for 30 min. The pH of the inactivated horse serum was adjusted to 6.0 using 1N hydrochloric acid and subsequently mixed with the Trichomonas medium. To suppress bacterial growth, 100 µg of chloramphenicol was added per milliliter of the Trichomonas culture broth. Aliquots' of 2–3 ml of the broth were dispensed into bijou bottles and stored at 2–8°C. The Trichomonas culture broth was brought to room temperature before inoculation of the organism.
Consecutive participants were recruited into the study after informed written consent was obtained and they were assured of strict confidentiality. Sociodemographic information and obstetric history were obtained using a pro forma. Scoring system for allocation into social class was as described by Olusanya et al. Pretest counseling for STI was conducted before specimens were collected from the participants. Vaginal smear was obtained from the posterior fornix of the vagina using two sterile swabs which were labeled accordingly. Samples collected were examined within 30 min of collection. In case of delay, a drop of normal saline was added to the swab stick container and stored in the refrigerator at 4–8°C and assayed within 1–3 h. Both microscopically trichomonads negative and positive high vaginal swabs (HVS) were inoculated in OXOID Trichomonas media enriched with horse sera and chloramphenicol to inhibit bacterial growth. The cultures were incubated at 37°C and their wet mount preparations were examined at an interval of 24 h from day 3 to day 7 before they were discarded. The participants who came back for their results were given posttest counseling and those infected were treated with their partners with 2 g of metronidazole using the patient-delivered-partner treatment (PDPT).
Data were analyzed with SPSS software version 16, SPSS Inc, Released 2007, (IBM, Chicago). The statistical analysis included descriptive and inferential statistics. Sociodemographic details were recorded, and the relationship between dependent and independent variables was analyzed with Fisher's exact/Monte Carlo's Chi-square test of independence. Statistical significance was set at <0.05.
| Results|| |
A total of 102 consented HIV-seropositive participants were enrolled into this study and examined for T. vaginalis vaginitis. [Table 1] shows the sociodemographic profile of participants enrolled in this study. The age of the women ranged between 16 and 44 years with a mean age of 31 years and standard deviation of 4.9 years. Most of the participants were in the age group of 30–44 years (62.7%). Most of the participants were of Hausa/Fulani ethnic group (52.9%), which was closely followed by the northern minorities (30.4%). Furthermore, most of the participants had tertiary education (38.2%) which was closely followed by those with secondary education (30.4%) and only 2% had no formal education. A larger proportion of participants belonged to the middle socioeconomic class (64.7%) based on Olusanya's socioeconomic classification. Ninety-eight percent of the participants were married and 74.5% were in their first order of marriage. A larger proportion of the participants were engaged in monogamous marriage (73.5%), while 26.5% were in polygamous marital settings.
Out of the 102 participants examined for T. Vaginalis, 6 were positive using both wet mount microscopy and culture, giving a prevalence rate of 5.9%. Among the positive HVS, 5 were culture positive while 3 were positive on wet mount microscopy. One of the specimens diagnosed as positive on wet mount microscopy was negative at culture. The sensitivity for wet mount microscopy was 40% while specificity was 99% compared with culture. [Figure 1] shows the distribution of T. vaginalis vaginitis among HIV-positive antenatal care service clients in Zaria.
|Figure 1: Distribution of Trichomonas vaginalis vaginitis among human immunodeficiency virus-positive antenatal care service clients in Zaria|
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The clinical manifestation of T. vaginalis infection among the participants revealed that 60% complained of vaginal discharge or vulval itching as against 20% who complained of pain on micturition or odor from vagina.
More than half of the women (52.9%) were in their second trimester of pregnancy. Similarly, 38.2% and 8.8% were in their third and first trimesters, respectively. Seventy-five percent of the women were multiparae, and 12.7% and 11.8% were primigravidae and grandmultiparae, respectively. About 92% of all the women were on antiretroviral (ARV) therapy while the rest were not on ARV drugs. From this study, 91.5% of the women were on highly active antiretroviral therapy for treatment of their disease while 8.5% were on prophylaxis for their unborn child.
There was no significant statistical association between age, educational level, social class, order of marriage, marital setting, parity, gestational age, duration of HIV diagnosis, ARV treatment, and the development of trichomoniasis among women. [Table 2] shows the relationship between some maternal characteristics and T. vaginalis vaginitis.
|Table 2: Association between some maternal characteristics and Trichomonas vaginalis vaginitis|
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| Discussion|| |
The prevalence of T. vaginalis vaginitis was found to be surprisingly low considering the fact that the population examined was HIV-seropositive antenatal clients. In this study, 5.9% of the participants were found to have T. vaginalis using one of the most sensitive techniques to detect the organism. This finding was at variance with the work of Uneke et al. in Abakaliki, Nigeria, and Nwadioha et al. in Jos, Nigeria., Furthermore, symptomatic T. vaginalis infection was 60%, of which the most common complaints were vaginal discharge and vulval itching which was similar to the findings in several other studies.,,,
There is a general consensus that the prevalence of T. vaginalis varies markedly according to the setting. Direct comparison between studies can therefore be difficult and can often not be generalized, however certain trends are evident. The age-specific prevalence rate was highest among the age range of 15–29 years which was similar to the findings of other workers in sub-Saharan Africa and South-Asian countries.,,,, Trichomoniasis was more common among women with tertiary education in this study as opposed to other studies who reported having low education as a risk factor for infection.,, Thus, it may be possible that better education was associated with better health-seeking behavior. In addition, all the women positive for T. vaginalis in this study were married and were of middle or low socioeconomic class. These findings were in keeping with the work of Fernando et al. who reported a considerable number of unemployed women as having trichomoniasis in their study.
The distribution of T. vaginalis vaginitis with respect to different trimesters of pregnancy may not be unconnected with the fact that most pregnant women register for antenatal care in their second and third trimesters, The highest infection rate was observed in the second trimester. This was similar to the findings of Ojurongbe et al. Trichomoniasis was noticed to be more prevalent among those who had had a previous pregnancy which is in keeping with the findings of Sutton et al. though not statistically significant in this study.
T. vaginalis may be identified in genital secretions using wet mount technique which was detected in about 58-82% of infected women in most series. The inclusion of the culture technique in this study which is the “gold standard” improves diagnostic accuracy. However, the major limitations of the culture technique are delay in diagnosis and the relative cost of running such a system. About 83% of the trichomonad-positive patients were diagnosed using culture as against 50% by wet mount microscopy, and the sensitivity of the wet mount preparation compared to culture was similar to other studies.,
One important limitation of this study is the relative small sample population which may account for failure of the study to demonstrate any statistical significant association between any of the sociodemographic or clinical variables and T. vaginalis vaginitis as in other studies.
Women positive for T. vaginalis in this study were offered metronidazole according to the Centers for Disease Control guidelines. Reinfection from an untreated partner is a potential source of repeat infections. PDPT or the provision of antibiotics to infected index person to deliver to their sex partner was utilized in this study. This is a potent alternative compared to the traditional partner referral system. This method had been found to be superior to the standard partner referral method for reducing repeat Chlamydia trachomatis and Neisseria gonorrhea infection in other studies.
Targeting prevention efforts to decrease the ongoing sexual transmission of T. vaginalis infection may require increased screening efforts. A significant proportion of those infected are asymptomatic (i.e., about 40%), routine screening for T. vaginalis among all HIV-positive pregnant women is advocated in Zaria.
Health education, increased rate of condom use, improved access to health care for HIV-positive women, and availability of ARV drugs may be responsible for the reduced prevalence of T. vaginalis among these antenatal women. Finally, individuals who routinely present to antenatal clinic for care may not be an absolute representative of the general HIV pregnant population in northern Nigeria. Hence, this limits one's ability to extrapolate findings of this study to the general HIV pregnant population.
| Conclusion|| |
The prevalence of T. vaginalis vaginitis among HIV antenatal clinic attendees in ABUTH, Zaria, was 5.9%. About 40% of the trichomonad-positive participants were asymptomatic. Finally routine screening of HIV-seropositive antenatal clients for T. vaginalis is cost-effective.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]