R. Matthew Chico
Department of Disease Control
Faculty of Infectious & Tropical Diseases
London School of Hygiene & Tropical Medicine
Keppel Street, London WC1E 7HT, United Kingdom
The first syndrome-based algorithms were developed in the late 1980s to
diagnose and treat Chlamydia trachomatis and Neisseria
gonorrhoeae cervicitis in pregnancy (Braddick MR et al. Genitourin Med.
1990;66(2):62-5). These contributed to the first syndromic management
guidelines of sexually transmitted infections (STIs) recommended by the
World Health Organization (WHO) in 1991 (2001; WHO/HIV_AIDS/2001.01).
These guidelines have made important contributions to reducing the
burden of curable STIs, particularly in low-resource settings where there remains a dearth of laboratory facilities and trained staff. Point of care (POC)
tests have since been introduced for syphilis in the antenatal care
setting to facilitate rapid treatment (Mabey DC et al. PLoS medicine.
2012;9(6):e1001233). Similar advances in POC testing for other curable
STIs have been lacking.
Within this context, Peters et al. (BJOG 2020 xxxx) conducted an
important non-randomised cohort study of HIV-infected pregnant women in
South Africa to evaluate POC screening and treatment for C.
trachomatis, N. gonorrhoeae, and Trichomonas vaginalis (n = 427; 51%)
compared to syndromic management (n = 414; 49%). Among women in the POC
screening group, 40.3% (95% CI: 35.6, 45.1) were positive for at least
one STI, 29.5% (95% CI: 25.2, 34.0) for C. trachomatis , 5.6%
(95% CI: 3.6, 8.3) for N. gonorrhoeae , and 20.1% (95% CI: 95%
CI: 16.4, 24.3) for T. vaginalis . Postpartum, when all women were
aetiologically tested, 39% fewer women had a curable STI who had been
POC screened and treated at enrolment compared to women who were
provided syndromic management (aRR 0.61; 95% CI: 0.35-1.05). Although
the upper bound of the 95% confidence interval crossed the null, the
intervention effect seems evident: POC testing and treatment reduced the
burden of STIs in pregnancy relative to syndromic management in this
setting.
The study was underpowered to detect differences in the incidence of
preterm birth (23% vs 23%; aRR 1.2; 95% CI 0.81-1.8) and low
birthweight (15% vs 13%; aRR 1.1; 95% CI: 0.66-1.7). Effect
modification may have contributed to diluting observable differences.
One-fifth of women in the syndromic management group were on
antiretroviral therapy at the time of enrolment (n = 80; 19%) compared
to less than one percent in the POC screening and treatment group (n =
4; 0.9%). Another effect modifier may have been use of cotrimoxazole
prophylaxis against opportunistic infections. Overall use was 4.8% (n =
40), but proportions were not available by treatment group. If
antiretroviral use is an indication, women in the syndromic management
group may have disproportionately received cotrimoxazole. While
cotrimoxazole was unlikely curative of STIs, it is one-part trimethoprim
and five-parts sulfamethoxazole, the latter being a sulfanomide. Another
sulfanomide combination, sulfadoxine-pyrimethamine, used to prevent the
consequences of malaria in pregnancy, has been shown to reduce adverse
birth outcomes among pregnant women with curable STIs (Chico RM et al.
Clin Infect Dis. 2017 Apr 15; 64(8): 1043–1051), and a recent mediation
analysis has demonstrated strong ‘non-malarial’ protective effects (Roh
M et al. The Lancet Global Health. 2020;8(7):e942-e53). Regardless of
these possible effect modifiers, Peters et al. provide key
evidence in support of randomised controlled trials that compare POC
screening and treatment versus syndromic management powered to improved
birth outcomes in a range of antenatal care settings. Is this the decade
of change?
No disclosures: A completed disclosure of interest form is
available to view online as supporting information.