(STD) ma... - AIDS Prevention Initiative in Nigeria

AIDS Prevention Initiative in Nigeria
Workshop on STD Management
March 17 – 22, 2002
Laboratoire Bacteriologie Virologie
Centre Hospitalier Universitaire Le Dantec
Université Cheikh Anta Diop
Dakar, Senegal
Workshop Report
INTRODUCTION
The AIDS Prevention Initiative in Nigeria (APIN) hosted a workshop on sexually transmitted disease
(STD) diagnosis and management in Dakar, Senegal from March 17-22, 2002. The workshop was held
in collaboration with Professor Souleymane Mboup's Laboratoire Bacteriologie et Virologie at Hopital le
Dantec, Cheikh Anta Diop Université. The workshop constituted another step in meeting the 18-month
milestones of the APIN program, which was to establish accurate surveillance of HIV and other STDs in
target states in Nigeria.
The main objectives of the APIN Workshop on STD Management were:
1. Update of current STD diagnostic procedures.
2. Review of STD management and treatment.
3. Practical session on lab methods and new technologies for STD diagnosis.
As seen through the Senegalese experience, understanding the determinants of STD prevalence and
controlling these rates in the population can play a critical role in decreasing the incidence of HIV
infection. Thus, improved epidemiological surveillance of STDs is a critical part of Nigeria's efforts to
prevent the spread of HIV.
LOGISTICS
Eleven participants from Nigeria, who represented laboratories
from different populations in Plateau, Oyo and Lagos States,
attended the workshop. These participants included laboratory
personnel, scientists and physicians involved in advising the
Nigerian government and the Nigerian Action Committee on
AIDS (NACA). In addition, there were several participants from
the Harvard School of Public Health (HSPH) and the laboratories
at Centre Hospitalier Universitaire (CHU) Le Dantec and
Université Cheikh Anta Diop in Dakar.
The workshop’s opening and closing sessions were held jointly with another workshop on Antiretroviral
Therapy, also sponsored by APIN and running concurrently. Hope Bryer, APIN’s Associate Director for
Educational Programs and workshop manager, opened the introductory session by welcoming the group,
outlining the objectives of the workshops, and introducing the workshop co-chairmen: Prof. Souleymane
Mboup, Director of the Laboratoire Bacteriologie Virologie at CHU Le Dantec; and Prof. Papa Salif
Sow, Director of the Department of Infectious Diseases at CHU Fann. During the opening ceremony, the
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epidemiology of STDs in both Senegal and Nigeria, as well as the use of syndromic versus laboratory
management of STDs, were discussed. The intervening days consisted of overview presentations on
various STDs at the beginning of each morning and afternoon session. These lectures covered topics
such as the epidemiology and pathophysiology of various STDs, as well as a variety of laboratory assays
and syndromic method algorithms used for detection of STDs. Each of the seminars was followed by
discussion and application of lab protocols to detect the various diseases discussed.
OPENING: PROGRESS AND FUTURE DIRECTIONS: HIV/AIDS
Workshop Co-Chair and Director of the Laboratoire de Bacteriologie Virologie at CHU Le Dantec, Prof.
Souleymane Mboup, officially opened the workshop by pointing out that we are 20 years into the HIV
epidemic with no evidence of abatement . He acknowledged that HIV death rates are declining due to
ARV treatment, and that Senegal has achieved some success in this area -- but they must fight to
maintain prevalence at 1.4%/year. Prof. Mboup stated that the success is also, in part, due to the fact that
treatment has become more affordable. He stressed the need to increase access, improve efforts,
develop more research, and find a vaccine. In Senegal, much progress has been made since 1985
including: training of researchers, significant transfer of technology, and reinforcement of capacity
building. He is proud to congratulate Senegal's two partners in this APIN project, Harvard and Nigeria,
and wished them all a productive workshop.
He was followed by the APIN Program Director, Dr. Phyllis Kanki, Professor at HSPH, who
summarized the APIN progress over the past 14 months. The main aims of the program are: surveillance,
targeted intervention, prevention of mother-to-child transmission, capacity building and training. She
described the recent Advisory Council’s directive to enhance training and laboratory support for HIV
therapy. Thus far, 20 programs have been funded and APIN now needs to focus on training for STD
diagnosis and management. She emphasized the fact that the high rate of STDs in HIV positive patients,
revealed the need to better understand interaction and devise appropriate interventions. Prof. Kanki
closed by thanking the technical organizers of the two workshops: STD Detection (Dr. A. Dieng Sarr,
HSPH; Prof. A. Gaye-Diallo, CHU Le Dantec and Prof. Dr. A. Gueye-NDiaye, CHU Le Dantec) and
ARV Therapy (Dr. M.A. Toure, HSPH; Dr. P.S. Sow, CHU-Fann).
His Excellency, Sir Sule Buba, Ambassador from Nigeria to Senegal, spoke on behalf of the Nigerian
government and reaffirmed the commitment of the Nigerians in managing the plight of HIV/AIDS in
their country. His Excellency stated that until the present , AIDS was not well addressed in the country
due to issues of instability, insufficient awareness, lack of support, and a number of cultural issues. He
commended the Senegalese for their efforts and for their ability to control the HIV epidemic in Senegal..
He further stated that Nigeria would like to mimic the work done in places like Senegal and Uganda.
Thus far, the APIN program has funded several programs in 3 target states. The program is partnered
with a number of multidisciplinary Nigerian groups, with a major focus on high-risk groups, mother-tochild transmission and HIV/AIDS education. His Excellency closed by thanking APIN, The Bill &
Melinda Gates Foundation, the Kennedy School of Government, HSPH, and the Government of Senegal
for their involvement in these projects. He reinforced that the goal of this workshop was to acquire
additional experience and exposure to techniques so that Nigerians could start working towards
replicating some of the results seen in Senegal.
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Finally, Prof. Seydou Badiane, adviser to The Honourable Awa Marie Coll Seck, Minister of Health and
Prevention of Senegal, explained that the positive results in Senegal were possible due to a number of
factors, including: governmental support, mobilization of field workers, the early partnership and
collaboration with Harvard University, and the use of a global approach. He echoed some of the
comments made by the other panelists and stressed the need for the international community to support
strategies and initiatives to acquire the necessary funds. Finally, he thanked the Nigerian government
and Bill & Melinda Gates for making this collaboration and workshop possible.
STD SURVEILLANCE AND SYNDROMIC MANAGEMENT
Dr. Ibrahim Ndoye, Chairman of the National AIDS/STD Control Program, gave an overview of
Syndromic Management and STD Treatment in Senegal. Senegal is one of the first countries to use
syndromic management, which can be used in conjunction with standard laboratory diagnostic methods.
Dr. Ndoye stressed that poor STD management contributes to HIV burden, and that any HIV program
should incorporate STD management. He also stated that in order for syndromic management to be
effective, the algorithms used must be simple and assessable and that health workers at all levels should
be trained in these methods.
This discussion was followed by a review of syndromic management of STDs at the primary care level in
Nigeria by Dr. S. Adewole, from Ibadan-East Local Government. During his talk, Dr. Adewole showed
HIV and STD statistics for Nigeria as well as data from a pilot project that was conducted in Ibadan. Dr.
Adewole discussed the problems with using an etiological-based treatment method, primarily the cost to
patients, lack of manpower, low level of technical skills available, lack of access to equipment, and
negative impact on treatment due to loss of follow-up. He also stressed the benefits of using a syndromic
management method and insisted that more primary health care workers should be trained on how to take
sexual histories, how to use a speculum, and how to recognize the various symptoms of STDs. The
discussion that followed covered a variety of topics regarding STD epidemiology and detection in
Nigeria, including:
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Need to acquire more accurate statistics regarding HIV rates in Nigeria.
Use of syndromic management can be effective; preliminary studies at various health centers
have shown that if people are properly trained, they do not need an MD to carry out diagnosis
and treatment; it is even more effective if antibiotics are easily attainable over-the counter.
Rates of syphilis appear to be high in rural areas / low in cities and syndromic management
seems to have made an impact on decreasing rates of syphilis.
Major challenge in Senegal with regard to maintaining program at national level: how to make
all STI drugs "essential drugs" for the country, need to put Cipro on the list (so it becomes
available, although urologists disagree and do not feel that it should be dispensed at primary
health centers).
Overall, if we want to effectively reduce HIV infection rates, we must address STIs.
Recommendations for tracing contacts: do not actively trace patients, must make patients
understand the risks - risk of re-infection & risk to partner, persuade them to bring their partners
in to the clinic for counseling (they usually do after counseling).
Issues with antibiotic resistance and the need for simple tests.
What about black market drugs? The distribution of drugs is good in Senegal, but they still have
a black market. (Of note, the quality of black market drugs has been tested and is known to be
relatively "good".)
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These lectures were followed by discussions of STD management experiences in both Ibadan and Jos, by
Drs. A. Oni (University College Hospital) and D. Egah (Jos University Teaching Hospital) respectively.
Both discussed that syndromic methods are being used at the sites, but the amount of etiologic tests that
are done primarily rely on the patients' ability to pay. They each gave summaries of the epidemiology of
various STDs, treatments used, and showed the algorithms for detection. They also discussed the
difficulties involved in follow-up and partner/contact tracing.
Finally, this session was closed by discussing experiences with the management and STD detection in the
cohort of female commercial sex workers (CSW) in Senegal. Social workers, Ms. Thioye and Ms.
Ndour, from the Institut d’Hygiene Sociale in Dakar, discussed the details and logistics regarding the
cohort, which has been followed since 1978. Currently, the HIV prevalence in commercial sex workers
(CSW) is 13%.
Drs. I. Traore, N. Diaye and Dia (CHU Fann) spoke more
specifically about STD rates in this cohort. The discussion that followed, covered
some logistic issues related to following the high-risk cohort:
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Who pays? Bills are covered by the government and various research
programs, services are free to all CSWs.
Is focus only on Dakar in Senegal? Senegal has STI centers in each town,
same program (sentinel surveillance).
Why do most women enter the profession? Economic reasons.
What about clandestine prostitutes? What is done to reach those groups? Go
to the area where they are and encourage them to come to the center, educate
them through public health measures.
What about male CSW? Not following male CSWs, but starting program for MSM.
What is involved with rehabilitation once a woman is diagnosed with HIV? Is she encouraged to
leave the profession? Inform her of risks, provide education, put on treatment, monitor ARV
therapy, continue to provide condoms, take card if diagnosed GC or chancroid (but she may still
work clandestinely).
LABORATORY SESSIONS
The lectures covered a number of STDs commonly seen in the population.
Professor A. Gaye-Diallo, of CHU Le Dantec, began the series with a general
overview of the role of the lab in management of STDs. Her seminar also
covered the various agents that cause STDs as well as all of the available tests
that can be used for diagnosis. She pointed out that each lab must select the
procedures they will use based on sensitivity and specificity, reliability,
reproducibility, feasibility, acceptability, and the purchasing power of patients.
Prof. Gaye-Diallo pointed out that the tests used should be cheap, simple, rapid,
convenient, and stable. Finally, she pointed out that all of the tests she
described are not routinely used in Dakar and that a lot of the molecular
biological tests are used for epidemiological studies, but
serological tests are commonly used for diagnostics.
The lectures over the remainder of the workshop covered topics related to a
number of STDs, namely: Haemophilus ducreyi (Dr. A. Dieng Sarr, HSPH); viral
STDs, including HTLV, human herpes virus, cytomegalovirus, and HIV (Dr. J. L.
Sankale, HSPH); Chlamydia (Dr. K. Sturm-Ramirez, HSPH); syphilis (Prof. A.
Gaye-Diallo, CHU Le Dantec); vaginitis and bacterial vaginosis (Gaye-Diallo,
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Sturm-Ramirez). For each of the STDs discussed, the lecturers covered epidemiology, pathogenesis,
laboratory tests, algorithms used for syndromic management, interactions of the respective STD with
HIV, and data from various studies regarding the respective STDs.
All of the laboratory sessions were conducted at Le Dantec laboratories. The sessions covered:
preparation of media for culturing Neisseria gonorrhoea, Candida and H. ducreyi; microscopic
examination for H. ducreyi, Candida, N. gonorrhea, Chlamydia and vaginitis; nucleic acid extraction
from a cervical swab; diagnosis of Chlamydia by polymerase chain reaction (PCR) and by a rapid test;
detection of vaginitis by sniff and pH tests; and, diagnosis of syphilis by RPR test and TPHA. A final
laboratory session was conducted to cover CD4/CD8 cell quantification by FACS sorting.
Overall, the participants found these lectures and laboratory sessions to
be very useful. It was discussed that these methods of STD detection
should be incorporated into laboratory procedures at each of the sites.
It was also agreed upon that protocols used in each of the labs across
the various sites should be standardized so that the results could
ultimately be compared. The opinion of the group was also that there
should be follow-up workshops to assess the progress that has been
made as well as provide updates on the management of STDs.
HIV DIAGNOSIS AND ARV THERAPY MONITORING
As the goal of the APIN project is ultimately to address the AIDS epidemic, the
workshop was tied together with a review of a variety of issues related to
conducting HIV/AIDS studies. Dr. A. Gueye Ndiaye, of CHU Le Dantec,
provided a thorough overview of HIV diagnostic methods. Dr. H. Diop, of CHU
Le Dantec, followed with a presentation regarding various techniques of
monitoring viral load in HIV-infected patients who are placed on ARV therapy.
She focused on Roche and bDNA techniques. Next, Dr. O. Obasanjo (APIN)
discussed the various issues concerning data collection in a clinical setting. He
addressed some critical points any data manager would need to consider when
initially setting up and following a cohort in medical research. Finally, Dr. E.
Macondo, from the Laboratoire Analyses Medicales in Dakar, Senegal, stressed
the importance of maintaining quality assurance (QA) at all levels of any monitoring program, including
sample collection, laboratory methods and data management. He stressed the importance of keeping QA
programs simple, delegating duties to people at all levels and maintaining a free flow of communication
at all times.
CLOSING REMARKS AND RECOMMENDATIONS
Prof. Kanki officially closed the workshop by thanking all of the people involved in managing and
assisting at the proceeding, in particular the organizers from HSPH and Senegal as well as thanking the
Nigerians for their participation. Prof. Kanki remarked that she was grateful for the formation of the
collaboration between Senegal and Nigeria in the APIN efforts and hopes to see this continue. She
encouraged the Nigerian participants to maintain communication and collaboration with the Senegalese
as issues and questions arose. Prof. Kanki also invited the Senegalese collaborators to travel to Nigeria
as APIN ambassadors to help in the Nigerian efforts to establish a National Program for HIV/AIDS and
other STD surveillance and monitoring. Finally, she expressed her gratitude towards the Senegalese for
being gracious hosts and assisting with an extremely productive and informative workshop.
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Professor J. Oli, from The University of Nigeria Teaching Hospital in Enugu, Nigeria, on behalf of the
other Nigerian participants, thanked everyone for the workshop. He commended the efforts of all of the
organizers and echoed Prof. Kanki's comments by stating that the group found the workshops to be very
helpful. Prof. Oli stressed that all of the Nigerian participants were particularly impressed with the way
operations are being run in Senegal and have seen the importance of establishing organizational
capabilities. He reiterated the commitment of the Nigerian government and the associated participants
throughout to the country to mimic the results seen in Senegal. Prof. Oli expressed the excitement of his
Nigerian colleagues to return to their respective sites in Nigeria to implement all that they had learned
over the course of the workshop. Further, he invited all those assembled to come to Nigeria in a few
years to witness all the positive changes that would take place. In closing, he too expressed his gratitude
towards the Senegalese hosts and encouraged them to continue the fruitful collaboration.
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