Original Article Gonorrhoea Infection Prevalence in Human Immunodeficiency Virus Positive Patients Based On Polymerase Chain Reaction Examination
Original Article Gonorrhoea Infection Prevalence in Human Immunodeficiency Virus Positive Patients Based On Polymerase Chain Reaction Examination
Original Article Gonorrhoea Infection Prevalence in Human Immunodeficiency Virus Positive Patients Based On Polymerase Chain Reaction Examination
Introduction
Gonorrhea transmitted is infection the second (STI) most in the common United sexually States and it
infects more than 700,000 people per year with an equal ratio between male and female.1 It was stated by
the United Nations Joint Program on Human Immunodeficiency Virus/Acquired (UNAIDS) that the
Immunodeficiency gonorrhea prevalence Syndrome in the general population in Indonesia was 20 to 31%
in 2004.2 Meanwhile, data from 2007 Integrated Biological and Behavioral Surveillance (IBBS) on the
prevalence of STIs in female sexual workers (FSWs) gonorrhea in Indonesia ranged between show that
16% the and prevalence 44%, with of
the highest incidence found in West Java.3
Correspondence: Diah Padjadjaran-Dr. Puspitosari, Hasan Faculty Sadikin of Medicine, General Universitas
Hospital Jl. e-mail: Pasteur diahpoppy@gmail.com
No. 38, Bandung, Indonesia
Established diagnosis of gonorrhea infection is gonorrhoeae) made through identification Neisseria in
gonorrhoeae the genital tract, (N.
rectal, pharyngeal, and ocular secretion, which can be done using several methods, such as microscopic
examination, culture, and molecular techniques.1,4–6 Polymerase chain reaction (PCR) examination with
a higher is sensitivity, one of the molecular from 90–100%, techniques than culture technique which has
68% sensitivity.4–7 This technique has been stated to replace the culture technique, including for
asymptomatic patients.7 to as Human HIV) infection immunodeficiency causes an immunosuppressed
virus (or referred
condition that could increase the number of STIs and lead to greater co-diagnosis condition.8,9 People
with active STIs are more prone to HIV infection, and vice versa. HIV positive patients who to transmit
are exposed HIV.9 to Some STIs also epidemiological have a greater data risk
have suggested that gonorrhea contributes to
International Journal of Integrated Health Sciences. 2014;2(1) 1 :1–8
Gonorrhoea Infection Prevalence in Human Immunodeficiency Virus Positive Patients Based on Polymerase
Chain Reaction Examination
increased HIV transmission.10 The frequency of
serostatus of the study population had already
mucosal HIV increases by 32–41% in gonorrhea
been determined and confirmed based on the
patients and its transmission risk increases to
procedures stated in the National Guideline for
approximately 2–5 times higher.11–14
HIV before the study. Sexually active HIV positive
of HIV Several infection factors are that HIV-infected contribute cell to the withdrawal increase
patients participate attending in this study. Teratai Fourty Clinic eight were males offered and to
in the genital tract as a part of the immune
33 females were enrolled after signing written
response and cluster of differentiation, in this
informed consent. Women having her menstrual
case the CD4, lymphocyte stimulation that will
period were excluded from the study. eventually
lead to increased replication of HIV.12
The subjects underwent history taking and presence From of the gonorrhea immunology increases
perspective, HIV shedding the
physical urethral examination. swab in male and Sample cervical was swab collected in female from
on the genital tract which attracts CD4 T
for PCR examination. Comprehensive data on
lymphocytes as a part of the inflammatory
patient’s characteristics and sexual history were
response against patogen.10,11,15 In addition to
obtained through history taking and medical the
viral sheddings, the fact that some people
records. The history taking, clinical examination, with risk sexual HIV and behaviors AIDS are becomes
still engaged the in key some factor high in
and Teratai specimens Clinic while collections the specimen were processing performed was in
STI co-infections, including gonorrhea, with HIV
conducted at the Biology Molecular Laboratory,
and AIDS.16–20
Microbiology Department, Faculty of Medicine,
Sexually transmitted infections in people with
Universitas Padjadjaran, Bandung. HIV suggest the
possibility that these people
The protocol of this study was reviewed may
These still infections be engaged could in be risky a risk sexual factor behaviors. for HIV
and Faculty approved of Medicine by the of Ethical Universitas Committee Padjadjaran- of the
transmission to uninfected population.16 Other
Dr. Hasan Sadikin General Hospital, Bandung.
studies also support this.9,17 Manning et al.18
Specimen collection kits (Roche) was used for
revealed that high-risk sexual practices still
urethral swab for male patients and endocervical
occur among some segments of HIV positive
swab for female patients. Transport medium
population. and prevent To the decrease secondary associated spread of morbidity HIV and
tubes specimens (Roche) to the were laboratory used for on transporting the day of the the STIs,
prevention efforts should focus on HIV
collection. Immediately after arrival at the positive
patients who are still engaged in high-
laboratory, the urethral and endocervical swab risk
sexual practices.
specimens were prepared for the PCR assay as Thus,
data regarding gonorrhea infection in
instructed by the manufacturer, kept frozen at
people screening, with and HIV treatment are critical of for HIV the to prevention, reduce HIV
-20 Transport °C, and medium analyzed tubes within were 14 thoroughly days of sampling. mixed
transmission.16,19 However, until recently, data on
and 100 mL was withdrawn and diluted to 1 mL
STI prevalence, including data on asymptomatic
with sucrose-phosphate medium. After that, 1
gonorrhea in individuals with HIV positive, are
mL of swab specimen diluent (F. Hoffmann-La still
limited.3,10,21
Roche Ltd., Basel, Switzerland), was added and of Until publication now, there available are on still the
limited prevalence numbers of
the for PCR.
prepared specimens were frozen at -20 °C
gonorrhea infection among HIV positive patients
The PCR assay was accomplished using Roche
in Indonesia; therefore this study aimed to
CT/NG Amplicor PCR kit and the amplification
determine the prevalence of gonorrhea infection
process was conducted by using a thermocycler in
male urethra and female cervix of HIV positive
machine. Roche CT/NG Amplicor PCR kit for N. patients Teratai Clinic, based Dr. on Hasan PCR
Sadikin examination General results Hospital, in
gonorrhoeae Brancburb, USA) (Roche is a qualitative Moecular in vitro System, test for Inc., the
Bandung.
detection of N. gonorrhoeae DNA in urine from symptomatic and asymptomatic males and in
endocervical swab specimen from symptomatic Methods
This performed study is to a 81 cross-sectional HIV positive patients observational who visited study
Teratai Clinic, Dr. Hasan Sadikin General Hospital Bandung, Indonesia. The subjects were taken in
consecutive admission in July 2012. The HIV
and asymptomatic females as evidence of N. gonorrhoeae is detected by infection. PCR amplification N.
gonorrhoeae of target DNA DNA and by hybridization capture of amplified target. After the
amplification, the amplified nucleotide sequences were detected using an enzyme immunoassay and the
A450s were then
2 International Journal of Integrated Health Sciences. 2014;2(1)
:1–8
Diah Puspitosari, Asmaja Soedarwoto, et al.
measured with a spectrophotometer (Multiskan;
intercourse at an average age of 19.5 years, while
Labsystems Ltd., Findland).
the average age of the subjects with a negative As
stated in the Operator’s Manual for the
PCR result were 21.3 years. Most of the subjects
Amplicor Analyzer, the results were seen in the
in this study were heterosexual. print out for the
flags. Interpretation of the results
The majority of subjects with homosexual is is
as confirmed follow: positive if the value result of for the N. gonorrhoeae examination
orientation Of the 29 subjects (60%) showed with positive gonorrhea PCR infection. results, materials
>3.5 and a negative result is confirmed
as many as 23 subjects were heterosexual, 3 if the
value of the examination materials <0.2.
subjects were homosexual, and 3 subjects were The
results were calculated by statistic test SPSS
bisexual (Table 4). 17.0 and presented descriptively
by percentage.
Table 1 The Baseline Characteristics of Results
Participants
Subjects of the study were 81 patients averaging 32.8 years old with the youngest age was 23
Variabel Sex
n %
years old and the oldest was 62 years old (data not of subjects shown). by Table sex, education 1 shows
the level, characteristics occupation,
Male Female 48 59 33 41 and marital status. The most frequently found characteristics of the subject were
male gender (59%), high school education (51%), self-
Education
No formal education 0 0 employed (43%), and
married (57%). We can see gave that positive of the results 81 and subjects, 52 subjects 29 people (64%)
(36%) were
Primary school Junior high school 4 4 5 5 negative (Table 2).
The average age of subjects with PCR positive result for N. gonorrhoeae in this study was
Senior high school 41 College 32 51 49 32 years old with the youngest being 23 years old for the and
subjects the oldest with being negative 62 years. PCR Meanwhile, results, the
Occupation
Self-employed 35 43 average age was 33 years
old with the youngest was 23 years old and the oldest was 44 years old (data not shown). Based on sex,
18 males (37%) and 11 females (33%) had positive PCR result for
Employee 21 Commercial sexual 1 worker
26 1
N. females gonorrhoeae (67%) were while negative 30 males (Table (62%) 3).
and 22
Fifteen subjects with positive N. gonorrhoeae PCR results were self-employed. A total of nine
Student/college student Unemployed 1 1 23 28 subjects were merchants, two of the subjects were the
owner of a beauty parlour, and the others an EO, were and owner a catering of a bike company. shop, a Of
tattoo the seven shop,
subjects with positive PCR results who worked as private employees, two subjects were hotel
Status
Single Married Widow 18 22 45 57 18 22 employees, two were salesmen, one was a social worker, and
the others were private employees of unknown As many as companies.
30% unemployed subjects showed positive results and 70% were negative. Subjects who
worked as commercial sexual workers and students gave negative PCR results.
Most of the subjects were married. Among subjects were married, with 9 positive were single, PCR result,
and 6 were 14 of widows them
or widowers.
Data show that the subjects with positive PCR result for N. gonorrhoeae had their first sexual
Eleven subjects (52%) who had more than 6 lifetime sexual partners showed positive PCR test results,
and 10 (48%) were negative. Most of the subjects in both groups stated that they always Fourteen use
subjects condoms wih during positive sexual PCR results intercourse. stated that they constantly used
condoms, 6 expressed that they sometimes used condoms, and 9 declared that they had never used a
condom during sexual intercourse. In patients with HIV
International Journal of Integrated Health Sciences. 2014;2(1) :1–8
3
Gonorrhoea Infection Prevalence in Human Immunodeficiency Virus Positive Patients Based on Polymerase
Chain Reaction Examination
infection in this study, the history of previous STI gonorrhea. was not Most associated of subjects with
with the incidence positive PCR of
result stated that they did not have a previous history of STIs.
Discussion
Belongia prevalence et of al.21 gonorrhea in Minessota infection found in that patients the
with HIV infection and AIDS was more common in the age group of 25–34 years. Bastos et al.22 in
Table 2 The Results of PCR N. gonorrhoeae
Rio de Janeiro found that gonorrhea in patients with HIV infection related to the young age of
Examination The Results of PCR N. gonorrhoeae
n Examination
approximately et al.23 in Amsterdam in the early found 30s. that In 2001, gonorrhea Stolte
%
infection in people with HIV and AIDS were more common at age less than 31 years. The average age of
subjects with N. gonorrhoeae positive PCR Positive Negative 29 52 36 64
result in this study was 32.1 years old. people, Gonorrhea probably is more because commonly at young
found age in young there Total 81 100%
is a tendency of high risk sexual intercourse, such as having sex with multiple sexual partners or without
using condom.21–24 In this study, gonorrhea was more commonly found in male
Table 3 N. gonorrhoeae PCR Result Based on Characteristic of Participants
Variabel
PCR N. gonorrhoeae Result
Positive Negative
Total
Sex
Male 18 30 48 Female 11 22 33 Education
No formal education 0 0 0 Primary school 0 4 4 Junior high school 2 2 4 Senior high school 15 26 41
College 12 20 32 Occupation
Self-employed 15 20 35 Employee 7 14 21 Commercial sexual worker 0 1 1 Student/college student 0 1 1
Unemployed 7 16 23 Status
Single 9 9 18 Married 14 31 45 Widow 6 12 18
4 International Journal of Integrated Health Sciences. 2014;2(1)
:1–8
Diah Puspitosari, Asmaja Soedarwoto, et al.
subjects than in females, i.e. 37% vs 33%.
constrained by the norms; thus less exposed to
Hamlyn et al.25 found that gonorrhea infection in
STIs due to less frequent sexual relations.26 people
with HIV were more commonly found in
Most of the subjects with positive PCR results
males than in females, i.e. 53% vs 17%. Studies
in this study were senior high school graduates. by
et al.13 Manning also et found al.18 the in New incidences York and of Gore-Felton gonorrhea
Individuals to have risky with sexual low behaviors. levels of Lu education et al.27 found tend
infection were higher in males than in females,
a significant association between the level of 84%
vs 16% and 59% vs 41%, respectively.
education and gonorrhea infection in people Norms
lead to differences in sexual behavior
with HIV. In this study, most subjects who were
between men and women. Women are more
infected with gonorrhea had lower educational
Table 4 N. gonorrhoeae PCR Examination Result Based on Sexual History of Participants
Variable
PCR N. gonorrhoeae Result Positive Negative
Total
Average age of sexual debut 19 21 Sexual orientation
Heterosexual 23 49 72 Homosexual 3 2 5 Bisexual 3 1 4 Number of sexual partners in the last month
0 person 11 16 27 1 person 15 33 48 ≥2 persons 3 3 6 Number of sexual partners in the last 3 months
0 person 8 12 20 1 person 16 30 46 ≥2 persons 5 10 15 Number of lifetime sexual partners
1 person 9 12 21 2–5 persons 9 30 39 ≥6 persons 11 10 21 Condom use
Never 9 11 20 Seldom 6 15 21 Always 14 26 40 STI history
Positive 12 31 43 Negative 17 21 38
International Journal of Integrated Health Sciences. 2014;2(1) :1–8
5
Gonorrhoea Infection Prevalence in Human Immunodeficiency Virus Positive Patients Chain Reaction Based
on Examination Polymerase
levels which was senior high school level or
incidence of gonorrhea and other STDs in men
lower. Most of the subjects with positive PCR
who have sex with men (MSM) patients with HIV
results were self-employed and employees. A
infection. study a significant conducted relationship by Castor between et al.28 in India occupation found
it is Based stated on that the data research on the by sexual Ghanem behaviors et al.30
and the incidence of gonorrhea. In the study,
of a sensitive nature are more at risk for bias.
subjects who worked as an employee or self-
Hamlyn et al.25 suggested the possibility of
employed with an income between $1,000–5,000
sexual relations or sexual partners reported by per
year had 3-fold higher risk for gonorrhea as it
the subjects affect research results. was partners.
possible for them to have sex with multiple
results In this stated study, that most they subjects always use with condom positive when PCR
Research conducted by Lu et al.27 in China
having sex. About 90% of subjects who were in
2005 found that gonorrhea in patients with
infected with gonorrhea in the study by Jin et HIV
infection were more frequent in unmarried,
al.33 declared that they always use condom when
widow, and widower subjects. Similarly, the
having sex. In this study, there was no significant study significant conducted association by Castor
between et al.28 the in India incidence found of a
difference infection. This between result condom was suspected use and gonorrhea due to a gonorrhea
and the unmarried status. This might
bias in reporting condom use by the subjects. In be
because the subjects who are not married,
addition, incorrect condom use is also suspected
widow, or widower, are likely to have no steady
as a risk factor associated with the transmission
sexual partner.27
of gonorrhea.33 inaccurate Studies regarding results due sexual to social behaviors desirability often give
bias
patients Study found by Hamlyn that et most al.25 subjects toward HIV exposed infection to and
recall.25,29,30 Social desirability bias might
gonorrhea stated inconsistent condom use. Only
increase in direct anamnesis data retrieval if it
less than 50% of subjects who stated that they is
compared to audio computer assisted self-
always use condom when having sex but more
interview because subjects tend not to disclose
than 25% of the subjects showed the positive the
The actual subjects data.25,30
with PCR positive result for N.
PCR to inaccurate results for research N. gonorrhoeae. data from This history may taken.25 be due
gonorrhoeae in this study had their first sexual
In this study, data on condom use history only
intercourse at the average age of 19.5 years. The
include the frequency of condom use without
majority of women with HIV infection who were
information about how the subjects use it. Lee
exposed to gonorrhea in Venkatesh et al.31 study
et al.34 in his research in Thailand found that had ages their of 16–20 first years sexual old. intercourse
First sexual between intercourse the
68.3% they always of patients use condom with HIV when infection having stated sexual that
at young age was closely related to the number
intercourse but 8.9% of them were exposed of
sexual partners, delayed marriage, as well as
to gonorrhea and other STIs. This result was
high-risk sexual behaviors affected by STIs.27,29
considered as the result of the fact that the Most of
subjects with a positive PCR result
questionnaire used in the study did not include in by
this Young have et al.32 heterosexual and Castor orientation. et al.28 found Studies a high
any Several question other about studies correct found condom that condom use.
use
incidence of gonorrhea in heterosexual subjects.
is associated with gonorrhea infection, although It
was suspected that it is related to the number
some did not reach statistical
significance.22,24,27,35 of multiple sexual partners and a history of
In research by Lu et al.27 in people living with
previous gonorrhea.28,32
HIV, most of the subjects who were infected than A
six total lifetime of 11/21 sexual subjects partners who had had positive more
by use gonorrhea condoms. claimed Similarly, that the they research rarely by or Bastos never
PCR results. Significant correlation between the
et al.22 in Rio de Janeiro stated that an increase
incidence of gonorrhea infection and the number
in the incidence of gonorrhea is associated with of
lifetime sexual partners was found in the
less consistent condom use. study conducted by
Venkatesh et al.,31 namely
History of previous STIs was not associated in
sexual women partners. with 2–3 A and study more regarding than 4 multiple female
with HIV infection the incidence in this of study. gonorrhea Majority in patients of subjects with
sexual workers by Jin et al.33 found that multiple
with positive PCR result stated that they do not
sexual partners was a risk factor for gonorrhea
have a previous history of sexually transmitted
infection. Reitmeijer et al.24 in his study found
infections. These results are in accordance with that
the number of multiple sexual partners in
the results of Rieg et al.20 on MSM patients with
the last 4 months was one of the risk factors for
HIV infection in Los Angeles in 2006 which found
6 International Journal of Integrated Health Sciences. 2014;2(1)
:1–8
Diah Puspitosari, Asmaja Soedarwoto, et al.
that a history of previous STIs was not associated
33% respectively. Identifying gonorrhea infection
with the incidence of gonorrhea. It is presumably
based on PCR examination should be considered
because not recognized most STIs by the are patients.20
asymptomatic so they are
for Positive routine screening N. gonorrhoeae test in HIV PCR positive results patients. were In
conclusion, the prevalence of gonorrhea
found in subjects with an average age of first
infection in male urethra and female cervix of
intercourse at 19.5 years old. In addition, positive
HIV positive patients based on PCR examination
results were more common in heterosexual in
Teratai Clinic of Dr. Hasan Sadikin General
subjects and those with more than six lifetime
Hospital Bandung were quite high, 37% and
sexual partners.
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