Determinants of Syphilis and Trichomonas Infections among Women Attending Selected Health Facilities in Kigali, Rwanda

Research Article

Austin J Nurs Health Care. 2021; 8(2): 1061.

# Determinants of Syphilis and Trichomonas Infections among Women Attending Selected Health Facilities in Kigali, Rwanda

Nzeyimana Z1,2*, Mochama M1, Dzinamarira T3 and Safari E1

¹Department of Public Health, Mount Kenya University, Kigali, Rwanda

²ICAP Global Health at Columbia University, Rwanda

³Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

*Corresponding author: Zephanie Nzeyimana, Department of Public Health, Mount Kenya University, Kigali, Rwanda; ICAP Global Health at Columbia University, Rwanda

Received: July 27, 2021; Accepted: August 18, 2021; Published: August 25, 2021

## Abstract

Background: Syphilis and Trichomonas are among more than 30 known Sexually Transmitted Infections (STIs). They make part of the four (4) most prevalent treatable STIs globally, together with Chlamydia and gonorrhea. They are associated with lifelong health problems, especially among women and their babies, including but not limited to exacerbation of HIV acquisition risks, preterm labor, birth defects, and deaths. This study was conducted to determine the prevalence and determinants of Syphilis and Trichomonas infections among women attending selected Health Facilities (HFs) in Kigali, Rwanda.

Methods: This study was a cross-sectional survey that collected data from 174 women who attended eight (8) HFs in Kigali, Rwanda from October 7 to December 6, 2019, for Outpatient Diagnosis (OPD) services. The HFs were purposefully selected while women participants were recruited using a systematic random sampling strategy. Vaginal swabs were microscopically examined for the presence of Trichomonas vaginalis and Syphilis was diagnosed using FaStep Syphilis Rapid tests to detect IgG and IgM specific to Treponema pallidum. The questionnaire captured information on the socio-demographic characteristics and sexual behaviors of the participants. Fisher exact test, Phi, and logistic regression were the main statistical analysis of the study.

Results: This study recruited 174 women; aged between 17 and 49 years old, with a mean age of 29 years. The findings show that 12% (21 out of 174) of the women had either Syphilis (9.8%) or Trichomonas (2.3%), but none had both. Syphilis infections significantly affected women living in slums (40%, p=0.001), with a history of STI before (15.2%, p=0.028), not always using a condom (14.9%, p=0.014), and self-reporting to have had one lifetime sex partner (23.5%, p= 0.002). Living in slums, not always using a condom, and self-report of one lifetime sex partner uniquely increase the risks of getting syphilis up to 6.305, 5.53, and 5.81 times compared to their counterparts who are not, respectively. Trichomonas infection was significantly high (p <0.01) among women in economic category one (18.2%, p=0.029), self-reporting to lack transport (13.6%, p <0.001) and health cover (12.5%, p <0.001) as barriers of not attending a health facility while they are sick. Lacking transport means and health cover uniquely exacerbate the risks of Trichomonas infection up to 36.7 and 22.32 times, respectively.

Conclusion: This study concludes that Syphilis and trichomonas infections are still major public health problems among women attending health facilities in Kigali, Rwanda. Therefore, there is still a need to enhance health promotion programs to improve healthcare-seeking behaviors and empower women to negotiate safe sexual activities.

Keywords: Determinants; Syphilis infection; Trichomonas infection

## Abbreviations

AIDS: Acquired Immune Deficiency Syndrome; aOR: Adjusted Odds Ratio; CI: Confidence Interval; DH: District Hospital; HC(s): Health Center(s); HF(s): Health Facility (ies); HIV: Human Immunodeficiency Virus

## Background

Sexually Transmitted Infections (STIs) are infections mainly transmitted from one person to another through sexual intercourse. However, in rare cases; other routes of transmission are possible including direct contact with contaminated blood for blood-borne STIs, or materials like towels or toilets for non-blood-borne STIs. Trichomonas and Syphilis, currently under study, are among more than 30 known STIs and make part of the four (4) leading STIs globally, together with Chlamydia and gonorrhea. Trichomonas is caused by a protozoon called Trichomonas vaginalis, while Syphilis is due to a bacterium in the family of spirochetae called Treponema pallidum.

STIs remain a major public health concern globally. Every year, more than 160 million people get infected with T. vaginalis [1]. This incidence of trichomonas was 88 times higher than that one of HIV in 2017; 160 versus 1.8 million [2]. While trichomonas was the most prevalent STI (5%) in 2012, syphilis was the last among the four leading STIs globally with 0.5%, together with Chlamydia (4.2%) and gonorrhea (0.8%) [3].

Women present the highest health problems of STIs. It is well documented that women are more exposed to syphilis and trichomonas than their male counterparts due to anatomical and socio-demographic reasons. Anatomically, women have a larger exposed surface of the genital parts including vaginal and labial areas, as opposed to the male organ (penis) in men, via which these infections can pass. More so, the vaginal mucosa is more susceptible to be affected when compared to the hardened penile skin [4]. Sociodemographic factors include increased financial dependence of the females on their male counterparts, especially in resource-limited countries, and transactional sex mostly reported in sub-Saharan Africa.

Women in Sub-Saharan Africa engage in transactional sex for basic needs, luxury life, or as a means to express love to men. Considering sex for basic needs, women engage in sex to survive because men in Sub-Saharan Africa are considered as the source of financial support to women while women recognize that they need men to live. This renders them more vulnerable to the HIV epidemic and other STIs. Regarding sexual activity for luxury life, women accept sexual activities to get modern materials to fit in with their peers in a higher category and for smart life with upcoming technological materials/gadgets. Regarding sexual intercourse as an object to show love, men are considered as providers and women have to do sex with them to show that they love and obey them [5].

Syphilis and trichomonas are associated with lifelong health problems. They increase the risk of getting HIV up to 3 times and more [6,7] by weakening the vaginal wall and accumulating HIV susceptible cells around the reproductive organs [8]. They disproportionately affect pregnant women and their babies. About 38% (350,000/900,000) of all births from syphilis-infected women presented one or more birth problems in 2012. WHO reported that, of all pregnant women infected with syphilis, there was an estimate of 143 thousand of early fetal deaths or stillbirths, 62 thousand of neonatal deaths, and 44 thousand preterm born babies and/or babies with birth weight below 2.5kg due to mother-to-child syphilis transmission (Congenital syphilis) [9,10]. Similarly, Trichomonas increases the risk of preterm births, stillbirths, and deaths of neonates during pregnancy [7,11].

As a response to the worldwide STI burden; WHO initiated a global STI strategy in 2017, calling for country-based actions to fight against STIs, to reduce the global STI burden. In the plan, countries are entitled to understand their national STI epidemics for a wellinformed action plan to foster continuum services of STI treatment and prevention [3]. Despite the above WHO call for STI prevention, several countries are still struggling to understand their national STI epidemic, especially those with low incomes, where both financial and healthcare resources are limited.

According to the Rwanda Demographic and Health Survey (DHS) of 2014/2015, STIs disproportionately affected women (13%) more than men (4%) in Kigali. Women from Nyarugenge district presented the highest prevalence (20%) of STIs than those from Gasabo (12%) and Kicukiro (10%). However, the survey relied on self-reported STI signs and symptoms to confirm the STI Cases [12].

Studies have proven the vital role of laboratory tests in STI diagnosis because as many as 70% of the treatable STIs remain asymptomatic [11]. The prolonged incubation period of Syphilis can mislead its symptom-based diagnosis. More so, Syphilis chancre is self-healed and can disappear within 21 to 42 days of its appearance. Its incubation period can go up to 90 days from the time of bacterial acquisition. Asymptomatic patients present the highest risk of disease transmission while patients with signs and symptoms of STIs present the lowest due to decreased sexual desire (libido).

Drug-resistant STIs pose can a public health threat. Although syphilis is still effectively treatable with penicillin, Treponema pallidum strains resistant to macrolides, a second line substitute to penicillin, have been reported [13]. Thus, the importance of early diagnosis and proper treatment of trichomonas and syphilis infections to prevent possible transmission of drug-resistant strains.

The present study was conducted to determine the prevalence and determinants of syphilis and trichomonas infections among women attending selected HFs in Kigali, Rwanda.

## Study area

This study collected data from 8 HFs; 2 District Hospitals (DH), and 6 Health Centers (HCs) including 4 HFs in Nyarugenge District, namely Muhima DH, Biryogo HC, Muhima HC, and Cor-unum HC; and 4 HFs in Gasabo District comprising Kibagabaga DH, Remera HC, Gihogwe HC and Kagugu HC.

## Study design and population

This study was a cross-sectional survey, collecting data from 174 women, aged between 17-49 years, selected using a systematic random sampling strategy by considering every fourth woman who attended selected HFs for Outpatient Diagnosis (OPD) services during the period of data collection ranging from October 7 to December 6, 2019.

## Sample size calculation

This study collected information from 174 women attending selected HFs in Kigali. This sample size was determined using the following formula:

$\textit{n}=\frac{\textit{z}^2{p(1-p)}}{d^2{}}$

Where: Z is the level of confidence at 95% Confidence Interval (CI) of 1.96, p is the current prevalence of STIs which is 13% among women in Kigali in 2015 [14], d is the margin of error held at 5%.

$\textit{n}=\frac{1.96^{2}0.13(1-0.13)}{0.05^{2}}$

$=\frac{3.8416\times&space;0.13\times&space;0.87}{0.0025}=174$

Therefore, the sample size was 174 women.

## Data collection methods

Laboratory data: Selected women signed informed consent before being tested for the infections. On one hand, Capillary blood specimens were used to screen them for syphilis infection using FaStep Syphilis Rapid tests. This test is 99.6% sensitive and 99.1% specific to Treponema pallidum IgG and IgM. On the other hand, vaginal swabs were collected from the women and examined using a light microscope for the presence of Trichomonas vaginalis. Laboratory test results were captured using a Laboratory data collection sheet.

To collect information on determinants, a questionnaire was developed to capture information on participants’ demography, socioeconomic characteristics, risky sexual behaviors, and environmental risk factors like living near a nightclub, football stadium, or in densely populated areas or where urbanization activities are taking place. The questionnaire was piloted for reliability and validity testing before actual data collection.

## Reliability and validity of data collection instruments

Reliability: A structured questionnaire was piloted on 15 female respondents at Muhima HC to detect possible confusion from any included question, appropriateness of questions order, acceptability of the questionnaire length, and repeatability of responses if different raters interview the same person. Moreover, the Reliability of the questionnaire was tested by computing Cronbach’s alpha which was 0.707 for variables in the category STI risk factors, which was acceptable for internal consistency. Moreover, Cronbach’s alpha for healthcare-seeking behaviors and barriers was 0.643, which could increase by adding more items. Finally, participants were given a questionnaire version, written in their mother tongue, and proof red by two reviewers for translation accuracy.

Laboratory techniques were performed adhering to Good Laboratory Practices (GLP), and following the Standard Operating Procedures (SOPs) and test kit’s manufacturer’s instructions. Quality control samples were run before testing participants’ samples for syphilis. Qualified laboratory personnel, with a valid professional license and more than 7 years of working experience in clinical diagnostic laboratories, performed microscopic identification of Trichomonas vaginalis from collected vaginal swabs.

Validity: A structured questionnaire was developed based on abroad range of known risk factors of STIs from peer-reviewed publications and WHO guidelines including the WHO questionnaire entitled “Illustrative Questionnaire for Interview-Surveys with Young People” (Cleland, 2014). Proposed statistics were computed from the pilot data to check whether current study questions can be answered, using developed data collection tools. Used faStep Rapid tests are 99.6% sensitive and 99.1% specific to Treponema pallidum IgG and IgM.

While conducting this study, predefined procedures for data collection, analysis and interpretation were vigorously followed to protect internal validity by preventing order and researcher biases. The research assistants were also trained on how to use the tools. To ensure the external validity of the research methods, capillary blood samples were used for syphilis testing and vaginal swabs were microscopically analyzed within 30 minutes of their collection.

## Statistical analysis

Data were entered in IBM SPSS version 21 and analyzed using descriptive statistics and cross-tabulation analysis of the software. Fisher exact and Phi tests were computed to find out whether there is a statistical relationship between the occurrence of syphilis and trichomonas and various women characteristics and health determinants, considering a 5% margin of error and confidence interval of 95%. In addition, Binary logistic regression was computed to find out the extent to which factors associated with trichomonas and syphilis uniquely predict the occurrence of these diseases.

## Results

This study was conducted to determine the prevalence of Syphilis and trichomonas among women attending eight (8) selected HFs in Kigali, Rwanda. It was also done to establish determinants of these infections among the women. This section presents study findings encompassing demographic characteristics of the study participants, the prevalence of syphilis and trichomonas, and risk factors associated with each of the diseases.

## Demographic characteristics of the study participants

Study women aged between 17 and 49 years of age with a mean age of 29 years, and 49% of them aged between 20-29 years. Out of 174 study participants; 82.8% of them were married (52.3%) and single mothers (30.5%), 84.5% were occupied by unpaid jobs, 60.9% were in economical category III, 59.8% had high school, and 36.8% primary as their highest education level attained, and 83.3% were from Gasabo district. Detailed information is found in Table 1.