Trends in the prevalence of HIV and syphilis among pregnant women under antenatal care in central Venezuela

Sexually transmitted infections (STIs) carry a significant medical, economic, societal and emotional burden, although this has been poorly characterized. Inexplicably, the fight to eradicate congenital syphilis (CS) has failed to attract international attention,1Schmid G.P. Stoner B.P. Hawkes S. Broutet N. The need and plan for global elimination of congenital syphilis.Sex Transm Dis. 2007; 34: S5-10Crossref PubMed Scopus (109) Google Scholar compared to HIV and other STIs. The magnitude of the burden of CS globally rivals that of HIV infection in neonates, but the disease receives little attention, even in those countries in which the seroprevalence of CS is higher than that of HIV. Fortunately, benzathine penicillin G remains an effective treatment for syphilis.2Majeroni B.A. Ukkadam S. Screening and treatment for sexually transmitted infections in pregnancy.Am Fam Physician. 2007; 76: 265-270PubMed Google Scholar Herein, we analyze trends in HIV and syphilis prevalence among antenatal women in Aragua state, central Venezuela. State regional health office data on antenatal HIV and syphilis testing from 2000 to 2005 were reviewed. A total of 140 336 (66.4%) out of an estimated 211 474 pregnant women attending antenatal clinics in 18 municipal sanitary districts were analyzed. This population belongs to the lowest socio-economic level and comes from different geographical areas of Aragua state (5500 km2 and 1 665 247 population). During 2000 to 2005, serum samples were obtained for a total of 148 554 HIV and 201 028 Venereal Disease Research Laboratory (VDRL) tests (some women were tested multiple times). HIV and VDRL testing was done using standard methods (with national quality control tests at the National Reference Laboratory and with molecular biology techniques used for the diagnosis of positive controls tested against regionally used HIV/VDRL tests). Quantitative VDRL testing was performed for positive samples. Thus, a positive VDRL was considered to indicate syphilis. HIV was tested with ELISA and confirmed with Western blot. If syphilis is serologically diagnosed, in the absence of symptoms, three doses one week apart were given of benzathine penicillin G, 2.4 million units intramuscularly. If syphilis was diagnosed at more than 20 weeks gestation, ultrasonography should be performed to test for fetal syphilis. In the case of HIV, each patient is individually assessed, but would be offered zidovudine as antiretroviral prophylaxis. In Venezuela, all women attending antenatal care are recommended to undergo different antenatal tests, including VDRL and HIV testing, and usually more than 65% of women are covered by those tests. Linear regressions were used to study trends over time. Of the samples obtained during the review period, 1621 (0.81%, 1.16% of the evaluated pregnant women) were VDRL reactive (mean of 270 per year, 0.81%) (range of titers from 1:2 to 1:64 dilutions) and 710 (0.5%, 0.51% of the evaluated pregnant women) were HIV reactive (mean of 118 per year, 0.7%). The data are shown in detail in Table 1. Overall, the prevalence of syphilis among pregnant women did not change significantly (p = 0.189), from 1.19% in 2000 to 1.44% in 2005, although the number of VDRL tests carried out increased significantly (p = 0.0395) (Table 1). The largest change occurred in 2002 (from 0.85% to 0.79%). Overall, the prevalence of HIV infection among pregnant women increased, from 0.41% in 2000 to 3.05% in 2005, although this change is not statistically significant (p = 0.160), in part because of the steady increase until 2004. The significant increase that occurred in 2004 (from 0.53% to 3.05%, Table 1) is not related to better availability of tests or to higher coverage in their use among pregnant women. As seen in Table 1, there was a reduction in the number of evaluated pregnant women that year, perhaps biasing the results compared to previous years. Apparently the pregnant women evaluated that year corresponded to a more urban, higher risk, population. There is no HIV epidemic in the region and the increase for the period including 2004 was not statistically significant (p > 0.05). In any case, these trends require further evaluation in the future.Table 1HIV and syphilis prevalence among pregnant women in central Venezuela (2000–2005).YearTotal pregnant womenEvaluated pregnant women%VDRL testsNo. of reactive sera%aNumber of VDRL reactive sera/number of VDRL tests × 100.Syphilis seroprevalence (%)bNumber of VDRL reactive sera/number of evaluated pregnant women × 100.HIV testsNo. of reactive sera%cNumber of HIV reactive sera/number of HIV tests × 100.HIV seroprevalence (%)dNumber of HIV reactive sera/number of evaluated pregnant women × 100.200033 70325 85376.7130 8613081.001.1920 1070.50.41200135 13625 12571.5134 6802130.610.8525 238630.20.25200234 46823 69068.7332 7271870.570.7926 655190.10.08200333 89027 28480.5140 2722890.721.0630 324210.10.08200436 97026 63172.0344 8704551.011.7132 7081410.40.53200537 30811 75331.5017 6181690.961.4412 9733592.83.05Total211 474140 33666.36201 02816210.811.16148 5547100.50.51Mean35 24623 38966.8333 5052700.811.1724 7591180.70.73SE261523827.27381460.100.142908520.40.47F2.7509.0690.52432.506.7832.4492.98P0.1720.03950.50910.1890.05980.19270.160SE, standard error.a Number of VDRL reactive sera/number of VDRL tests × 100.b Number of VDRL reactive sera/number of evaluated pregnant women × 100.c Number of HIV reactive sera/number of HIV tests × 100.d Number of HIV reactive sera/number of evaluated pregnant women × 100. Open table in a new tab SE, standard error. The overall VDRL prevalence of 0.81% in this study is comparable to others. For example, a study carried out in Nigeria reported a prevalence of 1.3% (n = 11 428)3Ozumba U.C. Oshi D.C. Nwokeji C.M. Anya S.E. Trends in seroreactivity for syphilis among pregnant Nigerian women.Sex Transm Infect. 1999; 75: 120Crossref PubMed Scopus (8) Google Scholar and a study in India analyzing the same years as ours reported a prevalence of 1.8% (n = 40 511)4Sethi S. Sharma K. Dhaliwal L.K. Banga S.S. Sharma M. Declining trends in syphilis prevalence among antenatal women in northern India: a 10-year analysis from a tertiary healthcare centre.Sex Transm Infect. 2007; 83: 592Crossref PubMed Scopus (14) Google Scholar. Recent studies in Brazil5Figueiro-Filho E.A. Senefonte F.R. Lopes A.H. de Morais O.O. Souza Junior V.G. Maia T.L. Duarte G. Frequency of HIV-1, rubella, syphilis, toxoplasmosis, cytomegalovirus, simple herpes virus, hepatitis B, hepatitis C, Chagas disease and HTLV I/II infection in pregnant women of State of Mato Grosso do Sul.Rev Soc Bras Med Trop. 2007; 40: 181-187Crossref PubMed Google Scholar and Nicaragua6Hoekstra C.E. Riedijk M. Matute A.J. Hak E. Delgado E. Alonso R.E. et al.Prevalence of HIV and syphilis in pregnant women in Leon, Nicaragua.Am J Trop Med Hyg. 2006; 75: 522-525PubMed Google Scholar reported prevalences similar to ours: 0.8% (n = 32 512) and 1.5% (n = 1059), respectively. For HIV, the overall prevalence of 0.7% in our study is comparable to, but higher than, that found in the Brazil (0.2%; n = 32 512)5Figueiro-Filho E.A. Senefonte F.R. Lopes A.H. de Morais O.O. Souza Junior V.G. Maia T.L. Duarte G. Frequency of HIV-1, rubella, syphilis, toxoplasmosis, cytomegalovirus, simple herpes virus, hepatitis B, hepatitis C, Chagas disease and HTLV I/II infection in pregnant women of State of Mato Grosso do Sul.Rev Soc Bras Med Trop. 2007; 40: 181-187Crossref PubMed Google Scholar and Nicaragua (0.0%; n = 1059)6Hoekstra C.E. Riedijk M. Matute A.J. Hak E. Delgado E. Alonso R.E. et al.Prevalence of HIV and syphilis in pregnant women in Leon, Nicaragua.Am J Trop Med Hyg. 2006; 75: 522-525PubMed Google Scholar studies. The main difference between these studies and our own in evaluating HIV infection and syphilis prevalence is that our analysis was based on a larger study population (140 336 pregnant women). During the past decade, the incidence of syphilis and other STIs has increased worldwide and is comparable to the AIDS pandemic.7Vasquez-Manzanilla O. Dickson-Gonzalez S.M. Salas J.G. Rodriguez-Morales A.J. Arria M. Congenital syphilis in Valera, Venezuela.J Trop Pediatr. 2007; 53: 274-277Crossref PubMed Scopus (8) Google Scholar These STIs increasingly affect particular risk groups, (e.g. pregnant women and neonates)1Schmid G.P. Stoner B.P. Hawkes S. Broutet N. The need and plan for global elimination of congenital syphilis.Sex Transm Dis. 2007; 34: S5-10Crossref PubMed Scopus (109) Google Scholar, 7Vasquez-Manzanilla O. Dickson-Gonzalez S.M. Salas J.G. Rodriguez-Morales A.J. Arria M. Congenital syphilis in Valera, Venezuela.J Trop Pediatr. 2007; 53: 274-277Crossref PubMed Scopus (8) Google Scholar, 8Navas R.M. Parra R. Pacheco M. Gomez J. Bermudez I. Rodriguez-Morales A.J. Congenital bilateral microphthalmos after gestational syphilis.Ind J Pediatr. 2006; 73: 935-936Crossref PubMed Google Scholar. Given this, the World Health Organization has proposed the ‘Strategy for the Global Elimination of CS’, the aim of which is to address this under-recognized health problem.1Schmid G.P. Stoner B.P. Hawkes S. Broutet N. The need and plan for global elimination of congenital syphilis.Sex Transm Dis. 2007; 34: S5-10Crossref PubMed Scopus (109) Google Scholar, 7Vasquez-Manzanilla O. Dickson-Gonzalez S.M. Salas J.G. Rodriguez-Morales A.J. Arria M. Congenital syphilis in Valera, Venezuela.J Trop Pediatr. 2007; 53: 274-277Crossref PubMed Scopus (8) Google Scholar Although the syphilis prevalence found in this study is low, we support the importance of such strategies and the continued screening of pregnant women, as this will help eliminate the adverse effects of undiagnosed and untreated syphilis.8Navas R.M. Parra R. Pacheco M. Gomez J. Bermudez I. Rodriguez-Morales A.J. Congenital bilateral microphthalmos after gestational syphilis.Ind J Pediatr. 2006; 73: 935-936Crossref PubMed Google Scholar Syphilis confirmation tests are not always available in countries such as Venezuela, which, coupled with the inability of some women to afford both VDRL and other tests, leaves the disease undetected and untreated; we support testing and treating syphilis, as has been recommended previously.3Ozumba U.C. Oshi D.C. Nwokeji C.M. Anya S.E. Trends in seroreactivity for syphilis among pregnant Nigerian women.Sex Transm Infect. 1999; 75: 120Crossref PubMed Scopus (8) Google Scholar Such a policy should ensure that no cases are missed, especially as the drugs used to treat syphilis are considered safe in pregnancy. It might also result in a further decline in syphilis prevalence. Treatment for syphilis has been benzathine penicillin G. A Cochrane review concluded that, although penicillin is effective for the treatment of syphilis in pregnancy and the prevention of CS, the optimal treatment regimen is uncertain.2Majeroni B.A. Ukkadam S. Screening and treatment for sexually transmitted infections in pregnancy.Am Fam Physician. 2007; 76: 265-270PubMed Google Scholar, 9Walker GJA. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database of Systematic Reviews 2001;3:CD001143. DOI:10.1002/14651858.CD001143.Google Scholar (The Center for Disease Control recommends benzathine penicillin G, 2.4 million units intramuscularly,2Majeroni B.A. Ukkadam S. Screening and treatment for sexually transmitted infections in pregnancy.Am Fam Physician. 2007; 76: 265-270PubMed Google Scholar the same scheme used in Venezuela.) In the case of HIV, preventive strategies should be enhanced given the possible increase that was seen in 2005. Despite national policies on antenatal testing, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women. Even with wide coverage of antenatal care, its quality must be under constant surveillance. Poor organization of services and the cost of screening are the principal obstacles facing programs.7Vasquez-Manzanilla O. Dickson-Gonzalez S.M. Salas J.G. Rodriguez-Morales A.J. Arria M. Congenital syphilis in Valera, Venezuela.J Trop Pediatr. 2007; 53: 274-277Crossref PubMed Scopus (8) Google Scholar Aspects such as the impact of decentralization on antenatal syphilis screening programs, on-site testing, use of health information systems and immediate treatment that can reduce CS case numbers should be addressed. Antenatal syphilis screening and treatment programs are as cost effective as many existing public health programs. This needs to be reinforced, even in areas of low prevalence, to avoid the unnecessary burden of STIs in pregnant women and children. We would like to thank Kendall Billick (McGill University, McGill Centre for Tropical Diseases and LGH, Division of Infectious Disease, Montreal, Canada) and Paul Vivas (Hospital Reg. Esp. N 1 Lic I. Garcia Tellez, IMSS, Merida, Mexico) for their critical reading and valuable comments on the manuscript. Conflict of interest: No conflict of interest to declare.

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