Sero-Prevalence of HIV and Syphilis Infection Among Pregnant Mothers Attended Labor Ward at Wolaita Sodo University Teaching Referral Hospital: A Five-Year Retrospective Study (2012-2016)

Sexually transmitted infections (STIs) such as HIV and Syphilis infections are the major public health problem in the developing countries. The prevalence of syphilis and HIV infections among pregnant women has been shown to vary by geographic areas, study population and time-period. Objective: The aim of study was to assess sero prevalence of HIV and syphilis and associated factors among pregnant women attended labor ward at Wolaita Sodo University Teaching and Referral Hospital. Method: Retrospective study was conducted using standard extraction format to assess the sero-prevalence of HIV and syphilis among pregnant women attending labor ward of WSTRH. Data were analyzed by using SPSS version 20.0 software and result was summarized using means and percentages and presented by using figure and tables. Descriptive statistics were used. Result: Overall prevalence of sexually transmitted infection among pregnant women in labor was 7.4% from these HIV sero-prevalence accounts for 3.8% and VDRL positivity enumerates to be 3.7%. HIV-syphilis co-infection was found to be 0.9%. Higher sero-prevalence of HIV, syphilis and co-infection rate was reported in 2016, among age category of 35-44 years. Conclusion and recommendation: Significant percentage of HIV, syphilis sero-prevalence and co-infection rate was found in this study with increased proportion in 2016. Strong antenatal screening and appropriate strategies should be devised for prevention and control of HIV, syphilis, in women of reproductive age.


Introduction
Sexually transmitted infections (STIs) are a group of infectious or communicable diseases in which their primary mode of transmission is through sexual contact and they are among the major causes of illnesses throughout the world particularly in the developing countries. They are extraordinarily common with an estimated 340 million new cases of "curable" infections (including syphilis) occurring each year worldwide in men and women aged 15-49 years [1]. The impact of STIs is particularly severe for women of reproductive age, since such infections have few symptoms and may go untreated until serious problems develop [2].
Human immunodeficiency virus (HIV) is an RNA virus that belongs to a family of viruses known as retroviruses and causes acquired immunodeficiency syndrome (AIDS). The virus is a highly variable which mutates very readily meaning it have many different strains, even within the body of a single infected person [3]. HIV infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells) and its infection leads to low levels of CD4+ T cells through different mechanisms [4].
Syphilis is one of the sexually transmitted infections and is a reportable disease caused by Treponema pallidum. The Labor Ward at Wolaita Sodo University Teaching Referral Hospital: A Five-Year Retrospective Study (2012)(2013)(2014)(2015)(2016) bacteria can survive only briefly outside of the body; thus, transmission almost always requires direct contact with the infectious lesion through acquired or congenital [5].
Syphilis is transmitted in utero by trans-placental passage of the Treponema. The risk of transmission is related to the maternal Treponema load; hence early maternal infection carries a much greater risk of transmission than late infection. Indeed, almost all babies born to mothers with untreated primary or secondary infection will be infected, but the likelihood of transmission and the severity of infection will fall with subsequent pregnancies as the mother's Treponema load will fall with time [6]. Syphilis and HIV co-infection is now increasingly common all over the world. One of the major concerns regarding the coexistence of HIV and syphilis is that syphilis, as other genital ulcer diseases, might facilitate HIV acquisition and transmission due to interfering with the natural mucosal and epithelial barriers and by causing local inflammation. Furthermore, syphilis has been found to decrease (at least transiently) CD4 T-cell counts and increase plasma viral load in patients chronically infected with HIV where both of which have been linked to increase in HIV transmission [7].
Early diagnosis and treatment of pregnant women who tested positive for syphilis have been shown to be effective in reducing still-birth, neonatal death and congenital infection by more than 55% [6,8]. Importantly, these interventions have been estimated to be highly cost-effective even in low in-come countries [6].
The prevalence of syphilis and HIV infections has been shown to vary by geographic areas, study population and time-period [9][10][11][12]. Thus, obtaining periodical estimates of the local epidemiological picture of these infections by monitoring various risk groups is essential for guiding clinical action, resource allocation, and intervention protocols to make progress toward elimination.

Study Setting
The study was conducted at Wolaita Sodo University Teaching Referral Hospital which is situated at southern of Sodo town, Wolaita Zone, 396 km from Addis Ababa, Ethiopia. It is serving people in catchment's area of 2 million people including neighboring Dawuro zone, Gamogofa zone, and Kambata Tambaro one. The hospital organized in department, case-teams and working hours are according to BPR standard. There are seven case teams, OPD, Emergency, Inpatient, Delivery, Dentistry and Ophthalmology. The hospital has 200 beds for inpatient service which is on medical, pediatrics, surgical gynecology and obstetrics ward. 2.2. Study Design A retrospective study was conducted to assess the seroprevalence of syphilis and HIV among pregnant women attended labor ward from 30/09/2012 to 30/09/2016.

Source Population
The source population were all pregnant women who attended labor ward in Wolaita Sodo University teaching referral hospital from 30, June 2012-30, June 2016.

Study Population
The study populations were all pregnant women who attended labor ward in WSUTRH from 2012 up to 2016 and fulfilling the inclusion criteria.

Inclusion Criteria
All pregnant mothers who attended and registered in the document during the study period.

Exclusion Criteria
All pregnant mothers with incomplete information (especially age, HIV & Syphilis status.) Sampling Techniques: Convenient data collection technique according to inclusive and exclusive criteria (2012-2016).

Data Collection Procedures
Demographic data was collected based on our inclusion and exclusion criteria from the record using well-structured record format (annex ii) from antenatal care clinical records. Laboratory data of sero-positivity of syphilis was obtained from Wolaita Sodo teaching and referral University hospital laboratory

Quality Assurance
The data was checked for consistency and completed registration or recording document.

Ethical Considerations
The ethical clearance was obtained from the Ethical review committee of Wolaita Sodo University, college of health science and medicine. Formal permission was also obtained from Wolaita Sodo University Referral Hospital. For reasons of privacy, all data were kept confidential. Anonymity of records was maintained by using client ANC registration number and unique code numbers used by service providers at Wolaita Sodo University teaching referral hospital.

Data Processing and Analysis
The preliminary data were checked and processed depending on the variables. Analyzed using SPSS Version-20 software and results were summarized using means and percentages andpresented by using graphs and tables.

Socio Demographic Characteristics
A total number of 4166 women were attended labor ward in 2012-2016 in Wolaita Sodo university teaching referral hospital (WSUTRH). Four thousand twenty two women (4022) were included the study with complete information that is important for the study. The majority, 62% was found in the age group of 25-34 whereas the least abundant one was found in the age category of 35-44 years old.

Sero-Prevalence of HIV among Pregnant Mothers
Overall prevalence of 299/4022(7.4%) mothers were found for either one of HIV or syphilis. HIV sero-positive prevalence of 3.8% were identified in this study of which the largest percentage, 13.2% were recorded in year 2016. On the other hand, the minimum percentage was shown in year 2013 with magnitude of 2.1%. The overall trend of HIV seropositivity was depicted irregular feature.

Sero-Prevalence of Syphilis among Pregnant Mothers
An overall prevalence of Treponema pallidum, 3.7% was detected among pregnant mothers with the highest seroprevalence noted in 2016 and the least percentage were found in years 2012 and 2013. Syphilis detection rate was shown an irregular trend across the years. Table 3

HIV-Syphilis Co-Infection, among Women Attended Labor Ward
From the total women included in the study 0.94% syphilis-HIV co-infection was observed. Eight seven 87(57.6%) women were positive for syphilis among HIV positive cases. Linear increasing trend of syphilis prevalence were found in the five years. The overall prevalence of sexually transmitted infections (HIV and syphilis) were highest in year 2016(28.9%) but the least abundant were noticed in 2014(4.4%). Irregular feature (decreasing and increasing) trends were found for overall infection among women who attended labor ward in WSUTRH.

Discussion
This study revealed that the sero-prevalence of HIV and Syphilis infections and the co-infection of HIV and syphilis rate among women attending labor ward at Wolaita Sodo University Teaching Referral Hospital, Sodo, Ethiopia. All women attending labor ward have to be screened for HIV and Syphilis at labor and delivery if they are not tested at ANC follow-up.
On the other hand, lower findings as compared with our study were also reported in previous literatures of 0.38% in India [44], 1.8% in South Ethiopia [45]. Moreover, the finding of the present study was also higher than to the adult (1.3%) and the women national HIV prevalence of Ethiopia (1.8%).
The variation of this finding compared to the national HIV prevalence may be as result of difference in sample size, study area coverage and study population. Where; the national prevalence done on the total population and covers all over the nation whereas our finding has focused only in one segment of the population and limited to one study area. But compared to the study conducted in rural hospitals of southern Ethiopia the variation may be due to difference in living conditions where living condition of urban people are more crowded than rural setting this facilitates the risk of HIV transmission.
The higher prevalence of HIV in studies conducted in Northern Ethiopia, Gondar may be due to socio-cultural difference where early marriage and tattooing can be considered as a main contributor for the variation. As compared with studies conducted in Addis Ababa, our finding was much lower. This could be attributed to the overcrowding living status of urban areas and access to sexual exposure risky behaviors are more common in urban areas than this study where these factors increase the transmissibility of HIV.
Syphilis remains a major cause of morbidity and mortality in the world despite the availability of effective treatment. Interventions including early ANC, massive screening and prompt treatment with antibiotics have been reported to reduce syphilis attributable-risks [46]. Sero-prevalence of syphilis in the current study was 3.7%, which was consistent with studies conducted in Gondar, 3.7% in Gondar [43], 3% in Madagascar [47], Brazil [31] Bangladesh [48] each, and 2.9% in Addis Ababa, Ethiopia [49].
In contrast, it was higher than 2.3% sero-prevalence in the study done in Gondar health centers [32], 1.6% in Tanzania [50], 1% in Gondar University Teaching Hospital [9]. However, it was lower than previous studies conducted in Northwest Ethiopia with magnitude of 13.7% [51] and 10% in Southwestern Nigeria [52].
The variation might be the result of differences in culture, socioeconomic status, prevention and control measures, risk factors, level of awareness, and methods used for diagnosis where previous cross-sectional studies used syphilis specific tests like Treponema pallidum hemaglutinnin antigens and fluorescent treponemal antibodies which can detect syphilis at early stage and after treatment. The lower prevalence of syphilis among the study population could be attributed to the increase in syphilis screening at the ANC and effective treatment with antibiotics in the last 10 years.
Syphilis has also acquired a new potential for morbidity and mortality through association with increased risk of HIV infection. Because of their common route of transmission as well as the fact that they are mainly blood borne infections, syphilis and HIV co-infection continues to be a public health problem especially in the low income settings. More specifically, syphilis causes genital ulcer and facilitates HIV entry and shading. Besides, it induces immune activation and favor viral replication, which in turn accelerate HIV transmissibility [53].
The rate of HIV and syphilis co-infection varies depending on the prevalence of both infections in the community or the patient group being studied, along with individual risk factors. HIV-syphilis co-infection, 0.9% in the present study is in harmony with a study conducted in Gondar, 1% [43] but higher than 0.3% in Tanzania [50] but lower than 2.2% reported in north Ethiopia [9]. In the contrary to this, our finding was higher than, 0.05% reported in Nigeria [53].
Strength of the study i. This study included a five year data with retrospective design so it could show the progress and weakness of the prevention policy ii. This is the first study conducted in WSUTRH so it could serve as a baseline study for future works Limitation of a study i. The use of only serological tests for the diagnosis of HIV and syphilis, which may lead to false positivity and negativity and, ultimately, underestimate or overestimate of the results of our study. ii. The study is pure descriptive so we can't analyze associated factors with sero-prevalence of HIV and syphilis.

Conclusion
This study showed significant proportion of HIV and syphilis sero-prevalence were detected, indicating that they are significant public health problems. Both HIV and syphilis revealed the highest percentage in 2016 this could show the trend is increasing across the years.

Recommendations
Based on the findings the following recommendations are given: i. Further studies on syphilis and HIV that includes different study sites are recommended ii. Health education about identified risk factors for HIV-HBV and prevention methods should be given to expectant mothers. iii. There should be a need to enhance antenatal screening to reduce and ultimately prevent vertical and horizontal transmission of HIV and syphilis. iv. Likewise, appropriate strategies should be devised for prevention and control of HIV, syphilis, in women of reproductive age. v. Moreover, societal factors that contribute to HIV and syphilis transmission need to be further studied in the general population, which will be helpful to prevent future HIV and syphilis transmission in the general population.