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

ArticleinSexually transmitted diseases 36(6):357-64 · June 2009with13 Reads
DOI: 10.1097/OLQ.0b013e3181a4f695 · Source: PubMed
Abstract
: 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.
    • "The Government of Kenya has identified Kisumu as one of the top three counties with a hyper-endemic HIV burden, with prevalence among women slightly higher than that of all of Kenya (20.3% versus 19.3%, respectively) and the median age of HIV acquisition significantly younger among women than men [30]. The literature shows that HSV-2 and BV are significantly associated with a risk for acquiring HIV [31], that HSV-2 increases the risk for BV [32], and that prevalent and incident HSV-2 infection is linked to an increased prevalence of BV [33][34][35]. A comprehensive approach to women's sexual and reproductive health would be of benefit in this setting. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: HIV antiretroviral-based intravaginal rings with and without co-formulated contraception hold promise for increasing HIV prevention options for women. Acceptance of and ability to correctly and consistently use this technology may create challenges for future ring-based microbicide trials in settings where this technology has not been introduced. We examined baseline factors associated with enrolling in a contraceptive intravaginal ring study in Kisumu, Kenya and describe notional acceptability (willingness to switch to a contraceptive ring based solely on information received about it). Methods: Demographic, psychosocial, and behavioral eligibility screening of women 18-34 years was undertaken. Testing for pregnancy, HIV, and other sexually transmitted infections (STIs) was also conducted. We compared enrollment status across groups of categorical predictors using prevalence ratios (PR) and 95% confidence interval (CI) estimates obtained from a log-binomial regression model. Results: Out of 692 women pre-screened April to November 2014, 463 completed screening, and 302 women were enrolled. Approximately 97% of pre-screened women were willing to switch from their current contraceptive method to use the intravaginal ring exclusively for the 6-month intervention period. Pregnancy, HIV, and STI prevalence were 1.7%, 14.5%, and 70.4% respectively for the 463 women screened. Women 18-24 (PR=1.47, CI 1.15-1.88) were more likely to be enrolled than those 30-34 years of age, as were married/cohabitating women (PR=1.62, CI 1.22-2.16) compared to those separated, divorced, or widowed. In adjusted analyses, sexual debut at less than 17 years of age, one lifetime sexual partner, abnormal vaginal bleeding in the past 12 months, condomless vaginal or anal sex in the past 3 months, and not having a sexual partner of unknown HIV status in the past 3 months were predictive of enrollment. Conclusion: High notional acceptability suggests feasibility for contraceptive intravaginal ring use. Factors associated with ring use initiation and 6-month use will need to be assessed.
    Full-text · Article · Jul 2016
    • "It looks like Chlamydia may be competitive with the presence of TV and NG which are low in most countries with high CT rates. In order to reduce HIV acquisition and other complications in lowresource countries, self-sampling is a promising way to reduce risk factors like AVF/BV, CT, and NG (van de Wijgert et al., 2006Wijgert et al., , 2009 Chersich and Rees, 2008). During previous work, we had noted that AVF in African antenatal patients was associated with the presence of NG (Donders et al., 1993aDonders et al., , 1993b), TV (Donders et al., 1993a), syphilis (Donders et al., 1993aDonders et al., , 1993b), and CT (Donders et al., 1991Donders et al., , 1993a). "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Is self-assessed vaginal pH measurement to detect abnormal vaginal bacterial microflora (AVF) an adequate prescreening method for detection of genital sexually transmitted infections (STIs)? Materials and methods: A total of 360 Ugandan women tested themselves with a gloved finger and a pH color strip. PCR for bacterial vaginosis (BV)-associated bacteria was tested by PCR for Mycoplasma hominis, Ureaplasma urealyticum, and/or Atopobium vaginae, while the STIs were diagnosed by positive PCR for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and/or Trichomonas vaginalis. Results: A strong correlation was found between self-assessed pH values and BV-associated bacteria (P<0.0001), but not with STIs, not as single infections, nor in general. Conclusion: Self-measured vaginal pH correlated well with markers of high-risk microflora types such as BV or aerobic vaginitis, but not with STIs. Hence, in a screening program addressing AVF in low-resource countries, extra specific tests are required to exclude STIs.
    Full-text · Article · Dec 2015
    • "The prevalence of BV in the US varies from 29 % in a nationally representative sample (where the prevalence was 3.1 times greater for African-American women compared to whites), 44 % in a group of women at high-risk for HIV [105], and 56 % among injection drug users [106]. Like TV, BV can also increase a woman's susceptibility to HIV infection [42, 107, 108]. Several studies have shown a strong association between TV and BV109110111112 , meaning that the two frequently occur as co-infections among women. "
    [Show abstract] [Hide abstract] ABSTRACT: Trichomonas vaginalis (TV) is likely the most common non-viral sexually transmitted infection (STI) in the world. It is as an important source of reproductive morbidity, a facilitator of HIV transmission and acquisition, and thus it is an important public health problem. Despite its importance in human reproductive health and HIV transmission, it is not a reportable disease and surveillance is not generally done. This is problematic since most persons infected with TV are asymptomatic. Metronidazole (MTZ) has been the treatment of choice for women for decades, and single dose has been considered the first line of therapy. However, high rates of retest positive are found among TV infected persons after single dose MTZ treatment. This has not been explained by drug resistance since in vitro resistance is only 2-5 %. Treatment failure can range from 7-10 % and even higher among HIV+ women. Treatment efficacy may be influenced by vaginal ecology. The origins of repeat positives need further explanation and better treatment options are needed.
    Full-text · Article · Aug 2015
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