ObjectiveTo develop a tool for estimating national trends in adult prevalence of sexually transmitted infections by low- and middle-income countries, using standardised, routinely collected programme indicator data.MethodsThe Spectrum-STI model fits time trends in the prevalence of active syphilis through logistic regression on prevalence data from antenatal clinic-based surveys, routine antenatal screening and general population surveys where available, weighting data by their national coverage and representativeness. Gonorrhoea prevalence was fitted as a moving average on population surveys (from the country, neighbouring countries and historic regional estimates), with trends informed additionally by urethral discharge case reports, where these were considered to have reasonably stable completeness. Prevalence data were adjusted for diagnostic test performance, high-risk populations not sampled, urban/rural and male/female prevalence ratios, using WHO's assumptions from latest global and regional-level estimations. Uncertainty intervals were obtained by bootstrap resampling.ResultsEstimated syphilis prevalence (in men and women) declined from 1.9% (95% CI 1.1% to 3.4%) in 2000 to 1.5% (1.3% to 1.8%) in 2016 in Zimbabwe, and from 1.5% (0.76% to 1.9%) to 0.55% (0.30% to 0.93%) in Morocco. At these time points, gonorrhoea estimates for women aged 15–49 years were 2.5% (95% CI 1.1% to 4.6%) and 3.8% (1.8% to 6.7%) in Zimbabwe; and 0.6% (0.3% to 1.1%) and 0.36% (0.1% to 1.0%) in Morocco, with male gonorrhoea prevalences 14% lower than female prevalence.ConclusionsThis epidemiological framework facilitates data review, validation and strategic analysis, prioritisation of data collection needs and surveillance strengthening by national experts. We estimated ongoing syphilis declines in both Zimbabwe and Morocco. For gonorrhoea, time trends were less certain, lacking recent population-based surveys.

Trend estimations using the Spectrum-sexually transmitted infection (STI) model based on survey and surveillance data from Morocco showed declining gonorrhea and chlamydia prevalence and incidence in adults over 1995 to 2015. Supplemental digital content is available in the text.

BackgroundEvolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation. We applied the Spectrum STI estimation tool to estimate the prevalence and incidence of active syphilis in adult women in Morocco over 1995 to 2016. The results from the analysis are being used to inform Morocco’s national HIV/STI strategy, target setting and program evaluation.MethodsSyphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics, women attending family planning clinics and other general adult populations, as available post-1995. Prevalence data were adjusted for diagnostic test performance, and for the contribution of higher-risk populations not sampled in surveys. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis.ResultsIn 2016, active syphilis prevalence was estimated to be 0.56% in women 15 to 49 years of age (95% confidence interval, CI: 0.3%-1.0%), and around 21,675 (10,612–37,198) new syphilis infections have occurred. The analysis shows a steady decline in prevalence from 1995, when the prevalence was estimated to be 1.8% (1.0–3.5%). The decline was consistent with decreasing prevalences observed in TB patients, fishermen and prisoners followed over 2000–2012 through sentinel surveillance, and with a decline since 2003 in national HIV incidence estimated earlier through independent modelling.ConclusionsPeriodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. This first-ever undertaking engaged and focused national stakeholders, and confirmed the still considerable syphilis burden. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012. From 2017 Morocco plans to implement a system to record data from routine antenatal programmatic screening, which should help update and re-calibrate next trend estimations.

IntroductionIn 2016, the World Health Assembly adopted the global strategy 2016–2021 for STI control through the health sector, with as impact target to reduce syphilis incidence by 90% from 2018 to 2030. We applied the Spectrum STI estimation tool to estimate national adult prevalence and incidence of active syphilis in Morocco currently and over 1995–2015, to inform its national HIV/STI strategy, target setting and program evaluation.MethodsSyphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics conducted during 1996–2012, and among women attending family planning clinics. Prevalence data were adjusted for diagnostic test performance. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis. Rates estimated for ANC women were assumed to apply to the overall female adult (15–49 years) population.ResultsIn 2016, syphilis prevalence was estimated to be 0.56% (95% confidence interval, CI: 0.3%–1.0%). Around 21,675 (10,612–37,198) new syphilis infections were estimated to have occurred in adult women in 2016. This is a decline from the prevalence estimate for 2000 of 1.38% (0.87%–2.1%).ConclusionPeriodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012, when no new surveys were conducted. Planned recording of results from routine antenatal programmatic screening, being rolled out from 2017, should soon allow updating and re-calibration of future estimations.

IntroductionEvolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation.MethodsThe Spectrum modelling tool estimated prevalence and incidence of gonorrhoea and chlamydia in Morocco’s 15–49 year-old population, based on prevalence data adjusted for diagnostic test performance, urban/rural and male/female differences, and missing high-risk populations, and weighted by coverage and representativeness.ResultsGonorrhoea prevalence was estimated at 0.37% (95% confidence interval, 0.14%–1.0%) in women and 0.32% (0.12%–0.87%) in men in 2015; chlamydia prevalences were 3.8% (2.1%–6.4%) and 3.0% (1.7%–5.1%). Corresponding numbers of new cases in 15–49 year-old women and men in 2015 were 79,598 (23,918–256,206) and 112,013 (28,700–307,433) for gonorrhoea, and 291,908 (161,064–524,270) and 314,032 (186,076–559,133) for chlamydia. Gonorrhoea and chlamydia prevalence had declined by 41% and 27%, respectively, over 1995–2015. Prevalence declines probably related to improved STI treatment coverage, and decreasing risk behaviours. Reporting completeness among treated urethral discharge (UD) cases was estimated at 46%–77% in 2015. Clinically reported UD cases corresponded to 13% of all (symptomatic and asymptomatic) gonorrhoea and chlamydia cases.ConclusionSTI declines and improvements in treatment coverage are consistent with Morocco’s introduction of syndromic management in 2000, scale-up of prevention interventions, and declining HIV incidence after 2003. While gonorrhoea is four-fold more common as cause of clinical UD cases than chlamydia, Morocco continues to suffer a large, untreated burden of chlamydia. Reliable monitoring of both STIs requires new periodic surveys and/or novel forms of affordable surveillance beyond high-risk populations.