The cervicovaginal environment and HIV incidence in Zambian women with female genital schistosomiasis

Background: In 2019, an estimated 56 million women were living with female genital schistosomiasis (FGS), a neglected tropical disease that results when eggs from the waterborne parasite Schistosoma (S.) haematobium are deposited in reproductive tissues. FGS has been associated with important sexual and reproductive health consequences, including ectopic pregnancy, infertility, and human immunodeficiency virus (HIV-1)acquisition. Inflammation in the female genital tract is likewise associated withHIV-1 acquisition and "non-optimal" cervicovaginal microbiota have also been associated with adverse reproductive consequences, including pelvic inflammatory disease, infections of pregnancy and the post-partum period and HIV-1acquisition. The cervicovaginal environment of women with FGS has not been fully described. The overall aim of this PhD thesis was to describe the cervicovaginal microbiota (including STI) and the cervicovaginal immune environment, focusing on cytokines and chemokines, in Zambian women with and without FGS and to explore the association of FGS with HIV-1 incidence. Methods: This PhD work was nested within the bilharzia and HIV (BILHIV) study, which recruited women aged 18-31, sexually active, and not pregnant from the HPTN 071 (PopART) Population Cohort, from which longitudinal information on HIV-1 infection status was available. Women enrolled in the BILHIV study (n=603) were assessed for FGS through self-collected genital swabs and clinic-collected CVL (n=527). For this PhD work, all BIL HIV participants with FGS (n=30) and all participants with probable FGS (n=25) were selected, and three FGS negative participants were selected for every FGS and probable FGS participant using a random number generator, frequency matched by age to participants with FGS. Among selected participants, cervicovaginal microbiota and STI were quantified using PCR and the associations of presence, median (IQR), and log concentration mean with FGS status were assessed. The concentrations of 17 soluble cytokines and chemokines were quantified in cervicovaginal lavage (CVL) by a multiplex bead-based immunoassay to evaluate the association between FGS and concentration of cervicovaginal cytokines and chemokines. To explore the association of FGS with HIV-1 incidence, the rate of HIV-1 seroconversion was assessed among women who wereHIV-1 negative at enrolment in the HPTN 071 (PopART) Population Cohort (n=492) and associations with FGS were evaluated with exact Poisson regression. Results: Of 603 women enrolled in BILHIV, 5.0% (30/603) had FGS, defined as PCR-detected Schistosoma DNA in any of three genital specimens (cervical swab, vaginal swab, or CVL). The prevalence of schistosome infection in the study population was 5.5% (33/603) by urine microscopy and 15.1% (91/601) by urine CAA. The presence and concentration of cervicovaginal species did not differ between participants with or without FGS. However, a higher proportion of participants with FGS had T. vaginalis compared to FGS negative women (p=0.08). An exploratory analysis suggested an association of T. vaginalis presence with FGS among women with ≥2 Schistosoma PCR positive genital specimens (50.0%, 8/16) compared with FGS negative (21.5% 34/158, p=0.01). There was no difference in the concentrations of cytokines or chemokines between participants with and without FGS. After adjusting for potential confounders, an exploratory analysis of women with genital specimens with detectable Schistosoma DNA (n=15) showed a higher Th2 (IL-4, IL-5, and IL-13) and pro-inflammatory (IL-15) expression pattern in comparison to FGS negative women. After adjusting for multiple testing, the association between IL-4 (p=0.037) and IL-5(p<0.001)and FGS were unlikely to be due to chance. Incident HIV-1 infections were observed in 4.1% (20/492) participants. Women with FGS were twice as likely to seroconvert as women without FGS but with no statistical evidence for a difference (RR 2.16, 95%CI[0.21±12.30], p=0.33). Exploratory analysis suggested a po int estimate consistent with increased risk of HIV-1 acquisition among women with ≥2 positive genital PCR specimens (RR 6.02, [0.58±34.96]), p=0.13), without statistical evidence of a difference after adjusting for potential confounders. Conclusion: FGS may alter the cervicovaginal environment, particularly in high burden infections. There are higher HIV-1seroconversion rates in women with FGS, although power to detect an association was limited in this analysis. The burden of disease should be assessed and correlated with outcomes in participants with FGS. Ideally, a longitudinal study would evaluate the interaction between FGS, HIV-1, and the cervicovaginal environment to provide additional depth to these findings

Beyond the barrier: Female Genital Schistosomiasis as a potential risk factor for HIV-1 acquisition.

Female genital schistosomiasis (FGS) results from egg-deposition in the female reproductive tract primarily by the waterborne parasite Schistosoma (S.) haematobium, and less commonly by Schistosoma (S.) mansoni. FGS affects an estimated 20-56 million women worldwide, mostly in sub-Saharan Africa. There is cross-sectional evidence of increased HIV-1 prevalence in schistosomiasis-infected women, but a causal relationship between FGS and either HIV-1 acquisition or transmission has not been fully established. Beyond the pathognomonic breach in the cervicovaginal barrier caused by FGS, this narrative review explores potential mechanisms for a synergistic relationship between S. haematobium infection, FGS, and HIV-1 acquisition through vaginal inflammation and target cell recruitment

Association between cervical dysplasia and female genital schistosomiasis diagnosed by genital PCR in Zambian women.

BACKGROUND: Female genital schistosomiasis (FGS) is a neglected tropical gynaecological disease that affects millions of women in sub-Saharan Africa (SSA). FGS is caused by Schistosoma haematobium, a parasitic carcinogen involved in the pathogenesis of squamous cell carcinoma of the bladder. Cervical cancer incidence and mortality are highest in SSA, where pre-cancerous cervical dysplasia is often detected on screening with visual inspection with acetic acid (VIA). There are no studies evaluating the association between VIA positivity and FGS diagnosed by genital PCR. METHODS: Women were recruited from the Bilharzia and HIV (BILHIV) study in Zambia a community-based study comparing genital self-sampling to provider obtained cervicovaginal-lavage for the diagnosis of FGS in women aged 18-31. FGS was defined as positive Schistosoma DNA from any genital PCR. Urogenital schistosomiasis diagnostics included urine circulating anodic antigen, urine microscopy and portable colposcopy. Participants were offered cervical cancer screening using VIA at Livingstone Central Hospital. Associations of PCR confirmed FGS and other diagnostics with VIA positivity were assessed using multivariable logistic regression. RESULTS: VIA results were available from 237 BILHIV participants. A positive Schistosoma PCR in any genital specimen was detected in 14 women (5.9%), 28.6% (4/14) of these women had positive VIA compared to 9.0% without PCR evidence of schistosome infection (20/223). Schistosoma PCR positivity in any genital specimen was strongly associated with VIA positivity (OR: 6.08, 95% CI: 1.58-23.37, P = 0.02). CONCLUSIONS: This is the first study to find an association between FGS and positive VIA, a relationship that may be causal. Further longitudinal studies are needed

The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire that has been developed in primary care to distinguish non-specific general distress from depression, anxiety and somatization. The purpose of this paper is to evaluate its criterion and construct validity. METHODS: Data from 10 different primary care studies have been used. Criterion validity was assessed by comparing the 4DSQ scores with clinical diagnoses, the GPs' diagnosis of any psychosocial problem for Distress, standardised psychiatric diagnoses for Depression and Anxiety, and GPs' suspicion of somatization for Somatization. ROC analyses and logistic regression analyses were used to examine the associations. Construct validity was evaluated by investigating the inter-correlations between the scales, the factorial structure, the associations with other symptom questionnaires, and the associations with stress, personality and social functioning. The factorial structure of the 4DSQ was assessed through confirmatory factor analysis (CFA). The associations with other questionnaires were assessed with Pearson correlations and regression analyses. RESULTS: Regarding criterion validity, the Distress scale was associated with any psychosocial diagnosis (area under the ROC curve [AUC] 0.79), the Depression scale was associated with major depression (AUC = 0.83), the Anxiety scale was associated with anxiety disorder (AUC = 0.66), and the Somatization scale was associated with the GPs' suspicion of somatization (AUC = 0.65). Regarding the construct validity, the 4DSQ scales appeared to have considerable inter-correlations (r = 0.35-0.71). However, 30–40% of the variance of each scale was unique for that scale. CFA confirmed the 4-factor structure with a comparative fit index (CFI) of 0.92. The 4DSQ scales correlated with most other questionnaires measuring corresponding constructs. However, the 4DSQ Distress scale appeared to correlate with some other depression scales more than the 4DSQ Depression scale. Measures of stress (i.e. life events, psychosocial problems, and work stress) were mainly associated with Distress, while Distress, in turn, was mainly associated with psychosocial dysfunctioning, including sick leave. CONCLUSION: The 4DSQ seems to be a valid self-report questionnaire to measure distress, depression, anxiety and somatization in primary care patients. The 4DSQ Distress scale appears to measure the most general, most common, expression of psychological problems

Sequencing and Comparative Genome Analysis of Two Pathogenic Streptococcus gallolyticus Subspecies: Genome Plasticity, Adaptation and Virulence

Streptococcus gallolyticus infections in humans are often associated with bacteremia, infective endocarditis and colon cancers. The disease manifestations are different depending on the subspecies of S. gallolyticus causing the infection. Here, we present the complete genomes of S. gallolyticus ATCC 43143 (biotype I) and S. pasteurianus ATCC 43144 (biotype II.2). The genomic differences between the two biotypes were characterized with comparative genomic analyses. The chromosome of ATCC 43143 and ATCC 43144 are 2,36 and 2,10 Mb in length and encode 2246 and 1869 CDS respectively. The organization and genomic contents of both genomes were most similar to the recently published S. gallolyticus UCN34, where 2073 (92%) and 1607 (86%) of the ATCC 43143 and ATCC 43144 CDS were conserved in UCN34 respectively. There are around 600 CDS conserved in all Streptococcus genomes, indicating the Streptococcus genus has a small core-genome (constitute around 30% of total CDS) and substantial evolutionary plasticity. We identified eight and five regions of genome plasticity in ATCC 43143 and ATCC 43144 respectively. Within these regions, several proteins were recognized to contribute to the fitness and virulence of each of the two subspecies. We have also predicted putative cell-surface associated proteins that could play a role in adherence to host tissues, leading to persistent infections causing sub-acute and chronic diseases in humans. This study showed evidence that the S. gallolyticus still possesses genes making it suitable in a rumen environment, whereas the ability for S. pasteurianus to live in rumen is reduced. The genome heterogeneity and genetic diversity among the two biotypes, especially membrane and lipoproteins, most likely contribute to the differences in the pathogenesis of the two S. gallolyticus biotypes and the type of disease an infected patient eventually develops