Time to turn the tide against trichomoniasis

Trichomoniasis is the most common curable sexually transmitted disease (STD) in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men, according to the Centers for Disease Control and Prevention (CDC).1 What can clinicians do to turn the tide?

Trichomonas vaginalis (TV) is the infectious agent that results in trichomoniasis. Interest in trichomoniasis has risen since research identified it as a risk factor for HIV. Women are especially at risk. Findings from one study indicate women with the infection have a 50% increased risk of acquiring HIV.2 Infection with TV in women and men already infected with HIV can be problematic. Research indicates that those coinfected shed more HIV in their secretions than those without the STD and put their partners at increased risk for HIV infection.3,4

While other STDs such as chlamydia and gonorrhea are reportable conditions, trichomoniasis is not. Research now indicates that the burden of TV infection is high and that asymptomatic infections are common.5 Results of a longitudinal study of men and women ages 18-26 indicate that TV was nearly as common as chlamydia and more common than gonorrhea.6 Study findings also revealed 95% of those with documented TV reported no symptoms in the week prior to testing.6

Pros of making TV a reportable disease

Should TV be added to the list of reportable diseases? Charlotte Gaydos, MS, MPH, DrPH, professor of medicine in the Division of Infectious Diseases at Johns Hopkins University, discussed the pros and cons at the 2010 National STD Prevention Conference.7

The evidence is "very strong" for making TV a reportable disease, Gaydos says. The prevalence of the infection, coupled with its association with pelvic inflammatory disease and adverse birth outcomes, and the identification of the infection as a risk factor for HIV, are all arguments for such a public health mandate. However, with the current economic downturn, it is unlikely that the CDC will be able to obtain additional national funding for such an effort, Gaydos says.7

While TV infection can cause symptoms such as vaginitis and cervicitis in women and urethritis in women and men, in most cases, the infection is asymptomatic.3 If it is not detected in women, trichomoniasis can lead to more serious consequences, such as pelvic inflammatory disease and preterm births.8,9

Since there is no standard guideline to screen for trichomoniasis , such as there is with chlamydia, many clinicians might think to test only when symptoms are present, says Jill Huppert, MD, MPH, assistant professor of pediatrics and obstetrics and gynecology at Cincinnati Children's Hospital Medical Center. Huppert and fellow researchers are focusing on better detection of the infection and looking at such options as rapid point-of-care tests and self-collected specimens in an effort to reduce transmission and potentially prevent future complications.

The most commonly used test to detect trichomoniasis is the wet mount; however, this in-office test detects only about 35-60% of infections in women.10 There are no good tests for TV in men.4 Culture can be used to test for infection, as well as two point-of-care tests: the OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Framingham, MA) and the Affirm VP III (Becton Dickenson, San Jose, California), a nucleic acid probe test.11

Treatment of TV is simple: Prescribe a single 2 gram dose of metronidazole or tinidazole.4 Be sure to treat the infected patient and partners; counsel that those treated should abstain from sex for the next week.4 Use the moment to offer testing for other STDs, including HIV, and offer prevention and counseling messages.4

Science eyes options

While trichomoniasis is a common sexually transmitted infection in adolescent women, barriers to diagnosis lie in the need for a pelvic exam and wet mount. Huppert and research associates have conducted a study to see if women ages 14-22 could accurately perform a point-of-care (POC) test on a self-obtained vaginal swab.12

In the study, 218 sexually experienced women collected a vaginal swab and performed a POC test for trichomoniasis. Using a speculum, the clinician obtained vaginal swabs which were tested for trichomoniasis using the POC test, wet mount, culture, and transcription mediated amplification, using standard and alternative primers. Self and clinician results were compared to true positives, which were defined as culture positive or transcription mediated amplification positive with both sets of primers.

Findings indicate that the women performing the test for themselves detected as many trichomoniasis infections as clinicians doing the same test or culture, and twice as many as detected with wet mount.12 In the future, incorporating self-performed tests into routine practice could increase identification and treatment of trichomoniasis in vulnerable women such as adolescents, researchers conclude. This final point is of particular importance, because Pap smear recommendations are now putting off pelvic exams to an older age in many adolescents, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University in Atlanta.

References

  1. Centers for Disease Control and Prevention. Trichomoniasis fact sheet. Accessed at www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm.
  2. McClelland RS, Sangare L, Hassan WM, et al. Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition. J Infect Dis 2007; 195:698-702.
  3. Hobbs MM, Kazembe P, Reed AW, et al. Trichomonas vaginalis as a cause of urethritis in Malawian men. Sex Transm Dis1999; 26:381-387.
  4. Wang CC, McClelland RS, Reilly M, et al. The effect of treatment of vaginal infections on shedding of human immunodeficiency virus type 1. J Infect Dis2001; 183:1,017-1,022
  5. Huppert J. Trichomoniasis: An update for clinicians. Accessed at www.physiciansofficeresource.com/articles.
  6. Miller WC, Swygard H, Hobbs MM, et al. The prevalence of trichomoniasis in young adults in the United States. Sex Transm Dis 2005, 32:593-598.
  7. Gaydos C. Trichomonas vaginalis — the undervalued STI. How to get respect. Presented at the 2010 National STD Prevention Conference. Atlanta; March 2010.
  8. Paisarntantiwong R, Brockmann S, Clarke L, et al. The relationship of vaginal trichomoniasis and pelvic inflammatory disease among women colonized with Chlamydia trachomatis. Sex Transm Dis 1995; 22:344-347.
  9. Kienstra AJ, Ward MA. Third place winner. Three-year-old female with intermittent ovarian torsion. J Emerg Med 2002; 23:375-377.
  10. Wiese W, Patel SR, Patel SC, et al. A meta-analysis of the Papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis. Am J Med2000; 108:301-308.
  11. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guideline 2006; accessed at www.cdc.gov/std.
  12. Huppert J, Hesse E, Hye-kyong K, et al. Adolescent women can perform a point-of-care test for trichomoniasis as accurately as clinicians. Presented at the 2010 National STD Prevention Conference. Atlanta; March 2010.