Treating girls and young women – the time is now
The HIV community is actively promoting male circumcision as a means to prevent transmission of HIV in Africa. Indeed, WHO states that: "There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%” thus recommending circumcision as a means of HIV prevention. WHO also states that: “Urogenital schistosomiasis is also considered to be a risk factor for HIV infection, especially in women”, however the HIV community has still not formally embraced regular treatment of girls and women against schistosomiasis to prevent HIV and other STDs.
The classical sign of urogenital schistosomiasis (affecting over 120 million people in Africa alone), is haematuria (blood in the urine). In women, urogenital schistosomiasis may present with a range of signs and symptoms including lesions of the cervix and vagina, vaginal bleeding, pain during sexual intercourse and nodules in the vulva. In areas endemic for urogenital schistosomiasis a large proportion of women may have female genital schistosomiasis (FGS). In 2009 a WHO working group on FGS concluded that there is biological plausibility that female genital schistosomiasis is a risk factor for HIV transmission to women. Genital schistosomiasis also affects men, inducing pathology of the seminal vesicles, prostate and other organs. This disease may also have other long-term irreversible consequences, including infertility. Bladder and ureteral fibrosis and hydronephrosis are common findings in advanced cases, and bladder cancer is also a possible late-stage complication.
The 2009 a WHO working group discussed the epidemiological association and recommended that Member States regularly treat all at-risk school-aged children with single-dose drugs against schistosomiasis and soil-transmitted helminth infections. It suggested that the policy of regularly treating school-age children with praziquantel should be reinforced and extended also to programmes for preventing HIV.
Earlier this year an International Scientific Workshop on Neglected Tropical Diseases (NTDs) took place in South Africa. The theme of the meeting was how schistosomiasis, in particular FGS, impacts on HIV. It concluded again that FGS was a cofactor for HIV transmission in endemic areas, and that the association between schistosomiasis and HIV had been corroborated by several scientific groups after the meeting of WHO of 2009. However, it also noted that regrettably the awareness of the association between HIV and FGS continued to be limited to a restricted group of key experts and that treatment had not been extended to girls and women to prevent HIV.
This led one audience member to comment: “Do we need to keep proving the links beyond doubt? Or should we just say that the effects of schistosomiasis and HIV are enough to treat. The fact that there could be an association is reason enough to start and continue with the collaborative effort of evidence gathering. For me, for now, I need to have started yesterday!” as reported by the couNTDown LSTM web page.
In 2009 Stoever et al, in an article in the Lancet entitled “HIV/AIDS, schistosomiasis, and girls”, argued that periodic and regular treatment with praziquantel should prevent the development of genital lesions, which increase HIV risk and cause gynaecological problems.
Praziquantel is safe and can be used during pregnancy and lactation. The Product Information Leaflet (PIL) of Cesol is clear on the matter referring to studies undertaken by the WHO. It states that pregnant women represent a high risk group and should receive treatment as a matter of priority if found with schistosomiasis or during large scale preventive chemotherapy interventions. Here is the clear cut statement from the PIL based on an extensive WHO analysis:
“The issue of schistosomiasis, pregnancy and lactation has been addressed by a meeting of experts at the WHO in Geneva in 2002. After reviewing two decades of clinical experience with praziquantel and the results of an extensive risk/benefit analysis, it has been recommended that, in areas where schistosomiasis is endemic, all pregnant and lactating women should be considered as high risk group and should be treated with Praziquantel” (Olds, 2003,WHO, 2002).
Next year Africa will have access to an unprecedented amount of praziquantel donated by Merck. It is time to assure that treatment of all girls and young women in Africa becomes agreed policy and not just the cause for a debate between a restricted group of researchers and public health experts.