Disentangling Contributions of Reproductive Tract Infections to HIV Acquisition in African Women

Academic Medical Center, Center for Poverty-related Communicable Diseases, Meibergdreef 9 T0-120, PO Box 22700, 1100 DE Amsterdam, The Netherlands.
Sexually transmitted diseases (Impact Factor: 2.84). 06/2009; 36(6):357-64. DOI: 10.1097/OLQ.0b013e3181a4f695
Source: PubMed


: To estimate the effects of reproductive tract infections (RTIs) on HIV acquisition among Zimbabwean and Ugandan women.
: A multicenter prospective observational cohort study enrolled 4439 HIV-uninfected women aged 18 to 35 attending family planning clinics in Zimbabwe and Uganda. Participants were interviewed, and tested for HIV and RTIs every 3 months for 15 to 24 months. They received HIV risk reduction counseling, male condoms, and treatment for curable RTIs.
: Despite HIV risk reduction counseling and regular screening and treatment for RTIs, the HIV incidence did not decline during the study. Positive HSV-2 serostatus at baseline (hazard ratio [HR] = 3.69, 95% confidence interval = 2.45-5.55), incident HSV-2 (HR = 5.35, 3.06-9.36), incident Neisseria gonorrhoeae (HR = 5.46, 3.41-8.75), and altered vaginal flora during the study (bacterial vaginosis [BV]: HR = 2.12, 1.50-3.01; and intermediate flora: HR = 2.02, 1.39-2.95) were independently associated with HIV acquisition after controlling for demographic and behavioral covariates and other RTIs (Treponema pallidum, Chlamydia trachomatis, Trichomonas vaginalis, and vaginal yeasts). For N. gonorrhoeae, C. trachomatis, T. vaginalis, and vaginal yeasts, the risk of HIV acquisition increased when the infection was identified at the visit before the HIV-detection visit or with the duration of infection. Population attributable risk percent (PAR%) calculations show that HSV-2 contributes most to acquisition of new HIV infections (50.4% for baseline HSV-2 and 7.9% for incident HSV-2), followed by altered vaginal flora (17.2% for bacterial vaginosis and 11.8% for intermediate flora).
: A substantial proportion of new HIV infections in Zimbabwean and Ugandan women are attributable to RTIs, particularly HSV-2 and altered vaginal flora.

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    • "Besides its high frequency, BV is associated with many adverse health outcomes [4-10] including pelvic inflammatory disease, unfavourable pregnancy outcomes and recently HIV. BV is not only associated with female acquisition of HIV [9,10] but also with female-to-male transmission of HIV, as reported in a recent study [7]. Though it is increasingly clear that BV results from the replacement of the lactobacillus dominated normal flora by a predominantly anaerobic flora, no single causal agent has yet been identified. "
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    ABSTRACT: BackgroundData on risk factors of recurrent bacterial vaginosis (RBV) are still scarce. We used data from female sex workers (FSW) participating in a randomized controlled microbicide trial to examine predictors of BV recurrence.MethodsTrial’s participants with at least an episode of BV which was treated and/or followed by a negative BV result and at least one subsequent visit offering BV testing were included in the analysis. Behavioural and medical data were collected monthly while laboratory testing for STI and genital tract infections were performed quarterly. The Andersen-Gill proportional hazards model was used to determine predictors of BV recurrence both in bivariate and multivariate analyses.Results440 women were included and the incidence rate for RBV was 20.8 recurrences/100 person-months (95% confidence interval (CI) =18.1–23.4). In the multivariate analysis controlling for the study site, recent vaginal cleansing as reported at baseline with adjusted hazard-ratio (aHR)=1.30, 95% CI = 1.02-1.64 increased the risk of BV recurrence, whereas consistent condom use (CCU) with the primary partner (aHR=0.68, 95% CI=0.49-0.93) and vaginal candidiasis (aHR=0.70, 95% CI=0.53-0.93), both treated as time-dependent variables, were associated with decreased risk of RBV.ConclusionThis study confirms the importance of counselling high-risk women with RBV about the adverse effects of vaginal cleansing and the protective effects of condom use with all types of partners for the prevention of sexually transmitted infections, including BV. More prospective studies on risk factors of BV recurrence are warranted.Trial registrationTrial registration: NCT00153777
    BMC Infectious Diseases 05/2013; 13(1):208. DOI:10.1186/1471-2334-13-208 · 2.61 Impact Factor
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    • "Decrease in the number of lactobacilli and overgrowth of diverse anaerobes is associated with an increased incidence of bacterial vaginosis (BV) [4,5], which is one of the most common vaginal syndromes among women in their reproductive age [6-8]. BV is associated with an increased susceptibility to sexually transmitted diseases including infection by human immunodeficiency virus-1 (HIV-1) [9-11] where the elevated vaginal pH associated with BV may allow the survival of HIV. Moreover, BV associated microbiota has been shown to enhance HIV-1 transcription and replication [12]. "
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    ABSTRACT: Background Bacterial vaginosis (BV), which is highly prevalent in the African population, is one of the most common vaginal syndromes affecting women in their reproductive age placing them at increased risk for sexually transmitted diseases including infection by human immunodeficiency virus-1. The vaginal microbiota of a healthy woman is often dominated by the species belonging to the genus Lactobacillus namely L. crispatus, L. gasseri, L. jensenii and L. iners, which have been extensively studied in European populations, albeit less so in South African women. In this study, we have therefore identified the vaginal Lactobacillus species in a group of 40 African women from Soweto, a township on the outskirts of Johannesburg, South Africa. Methods Identification was done by cultivating the lactobacilli on Rogosa agar, de Man-Rogosa-Sharpe (MRS) and Blood agar plates with 5% horse blood followed by sequencing of the 16S ribosomal DNA. BV was diagnosed on the basis of Nugent scores. Since some of the previous studies have shown that the lack of vaginal hydrogen peroxide (H2O2) producing lactobacilli is associated with bacterial vaginosis, the Lactobacillus isolates were also characterised for their production of H2O2. Results Cultivable Lactobacillus species were identified in 19 out of 21 women without BV, in three out of five women with intermediate microbiota and in eight out of 14 women with BV. We observed that L. crispatus, L. iners, L. jensenii, L. gasseri and L. vaginalis were the predominant species. The presence of L. crispatus was associated with normal vaginal microbiota (P = 0.024). High level of H2O2 producing lactobacilli were more often isolated from women with normal microbiota than from the women with BV, although not to a statistically significant degree (P = 0.064). Conclusion The vaginal Lactobacillus species isolated from the cohort of South African women are similar to those identified in European populations. In accordance with the other published studies, L. crispatus is related to a normal vaginal microbiota. Hydrogen peroxide production was not significantly associated to the BV status which could be attributed to the limited number of samples or to other antimicrobial factors that might be involved.
    BMC Infectious Diseases 01/2013; 13(1):43. DOI:10.1186/1471-2334-13-43 · 2.61 Impact Factor
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    • "The prevalence of syphilis in India is unknown but estimates from antenatal clinic attendees suggest a prevalence around 1.5%[5], [58]; estimates for syphilis among FSWs are closer to 20% [3], [5], [59]. There has been debate in the literature about the role of STIs in HIV transmission and particularly whether viral versus bacterial STIs play a more significant role and the difficulty in teasing apart independent effects [21], [22]. Our results suggest that, based on strength of effects, both viral (HSV-2) and bacterial STIs (syphilis and gonorrhoea) have a similar association with HIV prevalence overall. "
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    ABSTRACT: Approximately 2.4 million people are living with HIV in India. This large disease burden, and potential for epidemic spread in some areas, demands a full understanding of transmission in that country. We wished to quantify the effects of key sexual risk factors for HIV infection for each gender and among high- and low-HIV risk populations in India. We conducted a systematic review of sexual risk factors for HIV infection from 35 published studies. Risk factors analyzed were: male circumcision/religion, Herpes Simplex Virus 2, syphilis, gonorrhoea, genital ulcer, multiple sexual partners and commercial sex. Studies were included if they met predetermined criteria. Data were extracted and checked by two researchers and random-effects meta analysis of effects was conducted. Heterogeneity in effect estimates was examined by I(2) statistic. Publication bias was tested by Begg's test and funnel plots. Meta regression was used to assess effect modification by various study attributes. All risk factors were significantly associated with HIV status. The factor most strongly associated with HIV for both sexes was HSV-2 infection (OR(men): 5.87; 95%CI: 2.46-14.03; OR(women): 6.44; 95%CI: 3.22-12.86). The effect of multiple sexual partners was similar among men (OR = 2.46; 95%CI: 1.91-3.17,) and women (OR = 2.02; 95%CI: 1.43-2.87) and when further stratified by HIV-risk group. The association between HSV-2 and HIV prevalence was consistently stronger than other STIs or self-reported genital ulcer. If the strong associations between HSV-2 and HIV were interpreted causally, these results implied that approximately half of the HIV infections observed in our study population were attributable to HSV-2 infection. The risk factors examined in our analysis should remain targets of HIV prevention programs. Our results confirm that sexual risk factors for HIV infection continue to be an important part of Indian HIV epidemic 26 years after it began.
    PLoS ONE 08/2012; 7(8):e44094. DOI:10.1371/journal.pone.0044094 · 3.23 Impact Factor
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