Curable sexually transmitted infections (STIs) remain a major public health problem worldwide. However, the heightened public health focus on HIV control has overshadowed the control of curable STIs, despite the strong association between HIV and STI transmission.1 The STI burden continues unabated: in 2016, there were a combined 376 million new chlamydia, gonorrhea, syphilis, and trichomoniasis infections, with the greatest burden in low-income countries.2
Malawi bears a substantial STI burden, with 1 million cases of genital discharge and/or ulcer symptoms reported among persons aged 15 to 49 years in 2015 to 2016.3 Because of a lack of microbiological surveillance, laboratory-confirmed etiological data for individual STIs are not routinely available.3 The World Health Organization introduced syndromic STI management in 1991 and Malawi adopted the practice in 1992,4 but data on STI syndromes in Malawi are limited to periodic HIV program reports and demographic health surveys.5
To continuously monitor STI syndromes in Lilongwe, Malawi, we collaborated with the Kamuzu Central Hospital (KCH) in 2006 to establish a clinical electronic database. In this report, we describe trends in STI syndromes among patients at the KCH STI clinic during a 10-year period.
MATERIALS AND METHODS
We analyzed electronic data collected at KCH STI clinic between January 2006 and December 2015. Kamuzu Central Hospital is a tertiary hospital for the central region of Malawi, which has a population of 7 million people.6 Clinic attendees were either self-referred or provider referred. HIV counselors, nurses, clinical officers, and a medical doctor staffed the clinic. The KCH STI clinic closed in 2016 when KCH transitioned to referral-based care and STI services were moved to a district facility.
Our study population included all patients attending the clinic during the study period, with no exclusions. From July 2006, all STI patients were offered opt-out HIV testing and counseling before STI care.5 Patients had a paper file created with a unique identification number at their initial visit, and the files were retrieved at subsequent visits. Stickers bearing the number were placed on the paper file and in the patient’s health passport. We used the number in the patient’s health passport to identify patients at subsequent visits. Data were transcribed from the paper files to a Microsoft Access database after each visit.
Data included demographic information, HIV testing history, and clinical data. Sexually transmitted infection syndromes included genital ulcer disease, urethral discharge, lower abdominal pain, inguinal bubo, balanitis, genital warts, acute scrotal swelling, and abnormal vaginal discharge. All episodes for the same syndrome that occurred within 30 days for a given patient were regarded as follow-up visits and considered one episode.
We used descriptive statistics to summarize demographic characteristics. We calculated the percentage of patients with a positive HIV status at any point during the study period by counting both patients with a new diagnosis and those with a documented previous positive test, and dividing that number by the total number of patients with HIV status recorded at any point. HIV positivity in each year was calculated as the number of visits among persons with known HIV-positive status at the time of visit, divided by total visits among patients with HIV status known at the time of the visit in that year. We also calculated the percentage of visits in which each STI syndrome was observed in a given year. We stratified STI syndrome analyses by sex, describing trends over time with a nonparametric trend test for proportions, and calculating the relative change in the percentage of visits with a given syndrome between 2006 and 2015. We used χ2 test to compare categorical variables between men and women. Analyses were conducted using Stata SE version 14.1 (Stata Corp, College Station, TX). The National Health Sciences Research Ethics Committee and the University of North Carolina ethics review board approved this project.
A total of 47,733 unique patients attended the clinic across 68,192 visits in the study period. More patients were women (n = 27,591 [58%]) than men (Table 1). The median age was 28 years (interquartile range, 24–34 years), with men older than women on average (median age, 29 vs. 27 years; P < 0.001). The percentage of unique STI patients with HIV-positive status recorded at any point during the study period among those with a known status was 30%, with higher HIV burden among women than among men (32% vs. 28%; P < 0.001). HIV status was unknown for 20% of all patients. HIV positivity declined from 39% of visits in 2006 to 26% in 2015 (Supplemental Table 1 https://links.lww.com/OLQ/A547).
TABLE 1 -
Demographic Characteristics of Patients Who Attended KCH STI Clinic, 2006 to 2015
n = 20,142 (42.2%)*
n = 27,591 (57.8%)*
n = 47,733 (100%)*
| Median (IQR)
| 1 syndrome
| >1 syndrome
Demographic data were collected once during the initial visit. All calculations were per person using the initial STI clinic visit.
*Number of patients (men, women, and overall).
†HIV status was calculated as the percentage of patients with a positive HIV status at any point during the study period by counting both patients with a new diagnosis and those with a documented previous positive test result, and dividing that number by the total number of patients with HIV status recorded at any point.
‡The denominator for the percentage of patients with unknown HIV status is the total number of patients (men, women, and overall).
§Indeterminate refers to patients who had discordant serial HIV test results (Determine reactive and UniGold nonreactive). The denominator for the percentage of patients with indeterminate HIV results is the total number of patients (men, women, and overall).
¶Denominator is total number of visits.
Most (69%) patients were married, and 50% had at least some secondary education. Most patients had only 1 STI syndrome (55%) per episode, whereas 33% had more than 1 syndrome and 12% were asymptomatic. The most common STI syndromes across the study period among men were urethral discharge (50%), genital ulcer disease (25%), balanitis (11%), and inguinal bubo (9%; Fig. 1A). Among women, abnormal vaginal discharge (59%), lower abdominal pain (38%), genital ulcer disease (14%), and genital warts (9.5%) were the most common syndromes (Fig. 1B).
Among men, the percentage of visits per year for inguinal bubo decreased from 11% in 2006 to 2.5% in 2015, a relative decrease of 77% (P = 0.05; Fig. 2A). Among women, the percentage of visits for lower abdominal pain decreased from 52% to 24% (P = 0.003), whereas the percentage of visits for inguinal bubo also decreased (P = 0.03), and that for genital warts increased from 8.4% to 12.4%, a relative increase of 47.6% (P = 0.02; Fig. 2B). All other syndromes remained stable (Figs. 2A, B).
In this 10-year survey describing STI syndromes in Lilongwe, Malawi, genital discharge syndromes were the most common among both men and women, and genital ulcer syndrome and lower abdominal pain were the second most common syndromes among men and women, respectively. This picture is similar to those in Malawi HIV program and demographic health survey reports.3,5,7 Between 2006 and 2015, the burden of most STI syndromes remained stable except for the following: genital warts, which increased in women; lower abdominal pain, which decreased in women; and inguinal bubo, which decreased in both men and women. HIV remained a common coinfection. To our knowledge, this is the first report detailing STI syndrome surveillance among STI clinic patients in Malawi.
In our study, the burden of genital discharge was high and stable over time. Similar to previous reports,8 urethral discharge remains highly common among men in Malawi. Recently, etiology of urethritis in Malawian men was Neisseria gonorrhoeae (80%), Chlamydia trachomatis (9%), and Trichomonas vaginalis (3%).9 This picture mirrors those in Zimbabwe10,11 and South Africa.12N. gonorrhoeae has been the commonest etiology in Malawi since the early 1990s,13 whereas C. trachomatis has increased (from a low of 0.5% in 2004)14 and T. vaginalis has decreased (from a high of 20% in 2004).14 The decrease in T. vaginalis is attributed to the addition of metronidazole to the syndromic treatment of urethral discharge in 2008.15
Among women, abnormal vaginal discharge remains the most common syndrome in Malawi.3,8 Similar to regional reports,16,17 most vaginal discharges in Malawi are due to vaginal infection from T. vaginalis, Candida albicans, and bacterial vaginosis compared with cervical infection from N. gonorrhoeae or C. trachomatis.5 However, the diagnosis of abnormal vaginal discharge is less sensitive because it is graded clinically by risk of cervical infection that is usually asymptomatic.5 Etiology studies using nucleic acid amplification testing for better accuracy are required to inform treatment guidelines in Malawi.
Gentamycin has been used for treatment of gonorrhea in Malawi for more than 30 years, whereas other countries have discontinued its use because of resistance.11,12,18 Previous studies in Malawi have shown high susceptibility of N. gonorrhoeae isolates to gentamycin in vivo with high clinical cure rates.13,19 Currently, our team is reevaluating the antimicrobial resistance profile of N. gonorrhoeae in this setting.
In our study, genital ulcer disease burden was also high and stable over time. Similar to regional data,20 the most common etiology of genital ulcers in Malawi is herpes simplex virus (HSV).21 Among HIV-positive patients, a majority of genital ulcers are caused by HSV-2 recurrences due to HIV infection.20,21 This may also be true for our study population. As effective antiretroviral treatment of HIV becomes more accessible, the burden of recurrent HSV-2 ulcers is likely to drop.20 In Malawi, despite no direct effect on ulcer healing, acyclovir has been part of syndromic management of genital ulcers since 2008.22 The role of acyclovir or other antivirals in syndromic management of genital ulcers in Malawi needs further evaluation.
Another common cause of genital ulcers in Malawi is Hemophilus ducreyi.23,24H. ducreyi burden in Malawi has been one of the highest in the region, ranging from 30% in 199924 to 15% in 2006.21 The regional burden of H. ducreyi has decreased over time, with 0% prevalence recently reported in Zimbabwe20 and Zambia25; however, the current situation in Malawi is unknown. As the burden of genital ulcer disease remains high in Malawi, an etiology study is imperative to inform treatment guidelines.
The burden of genital warts among women increased over time. We are unable to explain the reason for this trend with our data. However, because genital human papillomavirus (HPV) infection is strongly associated with genital warts and cervical cancer,5 ensuring routine cervical cancer screening using visual inspection with acetic acid and considering HPV vaccination for adolescent girls seeking STI care could be beneficial for cervical cancer/genital warts prevention in Malawi. The burden of lower abdominal pain decreased substantially over time. We hypothesize that variability in the method of making this diagnosis, which relies on bimanual examinations that are not always possible in busy STI clinics, may have led to the reduction. Inguinal bubo declined over time in both men and women. We believe the drop may be a surrogate of reduced H. ducreyi as discussed earlier, underscoring the need for an etiology study.
Acquisition of HIV and STIs is tightly linked.26 Sexually transmitted infections increase HIV shedding and susceptibility, and HIV increases STI acquisition risk.27 Although the reduction in HIV positivity over time most likely reflects a reduction of HIV prevalence in the community, the HIV burden among STI patients in our study remained very high. Patients with STI should continue to be prioritized in HIV prevention.
Our results are based on care-seeking behavior of symptomatic and asymptomatic, self-referred or provider-referred patients from a standalone, public STI clinic at a tertiary hospital in the largest city of Malawi. Findings may not generalize to broader outpatient populations, particularly in rural settings and primary/secondary care centers without stand-alone STI clinics. In addition, demographic data were collected once during the first visit and did not reflect changes over time for those with multiple visits. Despite these limitations, our data arise from the first electronic STI clinic registry in Malawi, allowing for detailed estimation of burden and trends of STI syndromes in this setting over a decade.
Our results suggest that current guidelines for the syndromic management of STIs may be adequate but are due for validation with etiology and antimicrobial sensitivity studies. We recommend HPV vaccination for all adolescent girls accessing STI care in Malawi. Lastly, we recommend intensifying HIV prevention approaches among STI patients, including preexposure prophylaxis, voluntary medical male circumcision, HIV treatment as prevention, and HIV self-testing for sexual partners.
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