Syndromic diagnosis (SD) of reproductive tract infections (RTIs), based on patient signs and symptoms, is a widely implemented strategy in sub-Saharan Africa. We assessed sensitivity and specificity of SD against laboratory testing for RTIs among recently-diagnosed HIV-infected patients in Tanzania.
A cross-sectional study was conducted among sexually-active HIV-positive adults ≥ 18 years (y) newly enrolling at the regional hospital HIV clinic in Bukoba Tanzania, 2012-14. Study procedures included an interview on current RTI symptoms (sores, discharge, dysuria), and a genital exam. A study nurse made the SD according to national RTI guidelines, verified by a medical doctor. Regardless of symptoms, laboratory testing of blood, urine samples and genital swabs for chlamydia trachomatis, neisseria gonorrhoea, herpes simplex virus 1/2, and treponema pallidum was conducted. Among women, we also tested for trichomonas vaginalis, bacterial vaginosis and vaginal candidiasis. We analyzed the sensitivity and specificity of syndromic RTI diagnosis against a gold standard of laboratory testing, and determined the positive and negative predictive values (PPV, NPV).
We enrolled 615 participants: 301 men, median age 35.8y (IQR (30-41) and 314 women, median age, 33.2y (IQR 27-38). Half the men (56.2%) and 42.7% of women were married, median number of sexual partners in the previous 6 months was 1 for both. Median CD4 cell count was 249cells/µL (IQR 82-398) among men and 294cells/µL (IQR 132-486), among women. One third of men were circumcised (34.2%) at a median age of 10 years (IQR 3-19). Among 301 men, 58(19.3%) reported genital symptoms, 53(17.6%) had signs on examination; and 83(27.6%) had a syndromic RTI diagnosis. Among women 117(37.3%) reported symptoms, 67 (21.3%) had signs, and 184(58.6%) had a syndromic RTI diagnosis. On laboratory testing, 108 (35.9%) men and 247 (78.7%) women has RTIs. Among men, SD had a sensitivity of 37% (95% CI 28%-47%) and a specificity of 77% (95% CI 71%-83%), with a PPV of 1.66 (1.16-2.38) and NPV of 0.81 (0.69-0.95). Among women, SD had a sensitivity of 62% (95% CI 55-68%) and a specificity of 52% (95% CI 40%-65%), with a PPV of 1.29 (0.98-1.68) and a NPV of 0.74 (0.56-0.97).
RTI prevalence was high. SD underestimated RTI prevalence in comparison to laboratory testing, particularly among men. Routine RTI screening through physical exam and laboratory testing should be implemented for all adults recently diagnosed with HIV.