Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina

BACKGROUND

Factors that influence shedding of HIV-1 infected cells in cervical and vaginal secretions may be important determinants of sexual and vertical transmission of the virus. We investigated whether hormonal contraceptive use, vitamin A deficiency, and other variables were risk factors for cervical and vaginal shedding of HIV-infected cells.

METHODS

Between December, 1994, and April, 1996, women who attended a municipal sexually transmitted diseases (STDs) clinic in Mombasa, Kenya, and had previously tested positive for HIV-1, were invited to take part in our cross-sectional study. Cervical and vaginal secretions from 318 women were evaluated for the presence of HIV-1 infected cells by PCR amplification of gag DNA sequences.

FINDINGS

HIV-1 infected cells were detected in 51% of endocervical and 14% of vaginal-swab specimens. Both cervical and vaginal shedding of HIV-1 infected cells were highly associated with CD4 lymphocyte depletion (p = 0.00001 and p = 0.003, respectively). After adjustment for CD4 count, cervical proviral shedding was significantly associated with use of depot medroxyprogesterone acetate (odds ratio 2.9, 95% CI 1.5-5.7), and with use of low-dose and high-dose oral contraceptive pills (3.8, 1.4-9.9 and 12.3, 1.5-101, respectively). Vitamin A deficiency was highly predictive of vaginal HIV-1 DNA shedding. After adjustment for CD4 count, severe vitamin A deficiency, moderate deficiency, and low normal vitamin A status were associated with 12.9, 8.0, and 4.9-fold increased odds of vaginal shedding, respectively. Gonococcal cervicitis (3.1, 1.1-9.8) and vaginal candidiasis (2.6, 1.2-5.4) were also correlated with significant increases in HIV-1 DNA detection, but Chlamydia trachomatis and Trichomonas vaginalis were not.

INTERPRETATION

Our study documents several novel correlates of HIV-1 shedding in cervical and vaginal secretions, most notably hormonal contraceptive use and vitamin A deficiency. These factors may be important determinants of sexual or vertical transmission of HIV-1 and are of public health importance because they are easily modified by simple interventions.

Mycoplasma hominis and Ureaplasma urealyticum in patients with sexually transmitted diseases

Mycoplasma hominis and Ureaplasma urealyticum can be isolated with considerable frequency from the human urogenital tract and are thought to cause various syndromes such as nongonococcal urethritis, pelvic inflammatory disease, pyelonephritis or infertility. The aim of this study was the evaluation of the presence of different genital pathogens in patients with sexually transmitted diseases (STD) and, in particular, the detection of mycoplasmas in individuals infected with genital microbes and an assessment of the presence of genital microorganisms in patients harbouring Mycoplasma hominis or Ureaplasma urealyticum. Furthermore, the occurrence of mycoplasmas in women with bacterial vaginosis was established. Specimens were collected from a total of 41,980 persons attending the Outpatients' Centre for Infectious Venero-Dermatological Diseases in Vienna from 1994 to 1996. Of all genital pathogens, Ureaplasma urealyticum was cultured most frequently in men and women. Mycoplasma hominis and Ureaplasma urealyticum were detected more often in the vaginal fluid than in the male urethra. By contrast, infection rates with Neisseria gonorrhoeae and Chlamydia trachomatis were higher in men than in women. In both men and women, trichomoniasis increased colonisation with Mycoplasma hominis, while mycoplasmas occurred less frequently together with genital candidiasis. Mycoplasma hominis was cultivated significantly more often in women with bacterial vaginosis than in those without. In contrast to urethral infections in men, cervical infections with Neisseria gonorrhoeae or Chlamydia trachomatis raised the incidence of Mycoplasma hominis in the vaginal fluid.

Detection of Neisseria gonorrhoeae and Chlamydia trachomatis in genitourinary specimens from men and women by a coamplification PCR assay

A coamplification PCR test for the direct detection of Neisseria gonorrhoeae and Chlamydia trachomatis in urethral and endocervical swabs and urine samples from men and women was compared to standard culture techniques. Processed specimens were amplified in single reaction tubes containing primers for both organisms, and PCR products were detected by a colorimetric microwell plate hybridization assay specific for each pathogen. Of 344 specimens from men, 45 (13.1%) urine specimens were PCR positive for C. trachomatis, 51 (14.8%) urethral swab specimens were PCR positive, and 29 urethral swab specimens (8.4%) were culture positive. After analysis of discrepancies, the resolved sensitivity and specificity of PCR for C. trachomatis were 96.2 and 99.3%, respectively, in urethral swab specimens, compared to 88.2 and 98.6% for urine specimens. Of the 192 specimens from women, 28 (14.6%) urine specimens were PCR positive for C. trachomatis, 32 (16.7%) endocervical specimens were PCR positive, and 19 (9.9%) endocervical specimens were culture positive. After analysis of discrepancies, the resolved sensitivity and specificity of PCR for C. trachomatis for endocervical specimens were both 100% compared to 100 and 99.4%, respectively, for urine specimens from women. In men, 68 (19.8%) urine specimens were PCR positive for N. gonorrhoeae, 73 (21.2%) urethral swabs were PCR positive, and 59 (17.2%) urethral swabs were culture positive. After analysis of discrepancies, the resolved sensitivity and specificity of PCR for N. gonorrhoeae were 97.3 and 97.0%, respectively, for urethral specimens compared to 94.4 and 98.5% for urine specimens. In women, 18 (9.4%) urine specimens were PCR positive for N. gonorrhoeae, 23 (12.0%) were endocervical swab PCR positive, and 15 (7.8%) endocervical specimens were culture positive. After analysis of discrepancies, the resolved sensitivity and specificity of PCR for N. gonorrhoeae were 100 and 99.4%, respectively, for endocervical specimens compared to 90.0 and 95.9% for female urine specimens. These results indicate that a multiplex PCR is highly sensitive for detecting both C. trachomatis and N. gonorrhoeae from a single urine or genital swab, providing a more cost-effective way of screening multiple pathogens.

Sexually transmitted diseases update

STDs have worldwide distribution and result in immense social and economic cost. Knowledge of the clinical signs, symptoms, current clinical tests, and treatment recommendations is important for all health care professionals.

Acceptability and usefulness of vaginal washes in premenarcheal girls as a diagnostic procedure for sexually transmitted diseases. The Child Protection Centre at the Winnipeg Children's Hospital

OBJECTIVE

To assess the suitability of vaginal washes as specimens for sexually transmitted disease diagnosis and determine the usefulness of PCR technology for Chlamydia trachomatis diagnosis in prepubertal girls.

STUDY DESIGN

Paired sets of vaginal secretions were collected with swabs and by vaginal wash from 138 prepubertal girls for evaluation because of alleged sexual abuse. Detection by culture of Neisseria gonorrhoeae and C. trachomatis was compared between the two sampling techniques. PCR techniques were also used to test 29 vaginal wash specimens for C. trachomatis.

RESULTS

In the prepubertal girls N. gonorrhoeae was detected in two wash specimens but in only one swab specimen; C. trachomatis was detected by culture in both paired specimens from two children and by PCR in vaginal washes from both of the two children positive by culture; PCR identified two other infected children.

CONCLUSIONS

A vaginal wash technique coupled with newer molecular amplification technology may be useful in the assessment of sexually abused children.

Periodic health examination, 1996 update: 2. Screening for chlamydial infections. Canadian Task Force on the Periodic Health Examination

OBJECTIVE

To update the 1984 recommendations of the Canadian Task Force on the Periodic Health Examination on the routine screening of asymptomatic patients for infection with Chlamydia trachomatis.

OPTIONS

Screening, with the use of culture or nonculture tests, of the general population, of certain high-risk groups or of all pregnant women; or no routine screening.

OUTCOMES

Rates of asymptomatic and symptomatic chlamydial infection, perinatal complications, longterm complications of infection (i.e., pelvic inflammatory disease, infertility and ectopic pregnancy), coinfection with other sexually transmitted diseases, disease spread, hospital care, complications of therapy and costs of infection and of screening.

EVIDENCE

Search of MEDLINE for articles published between Jan. 1, 1983, and Dec. 31, 1995, with the use of the major MeSH heading "chlamydial infections," references from recent review articles and recommendation by other organizations.

VALUES

The evidence-based methods of the Canadian Task Force on the Periodic Health Examination were used. Advice from reviewers and experts and recommendations of other organizations were taken into consideration. Prevention of symptomatic disease and decreased overall costs were given high values.

BENEFITS, HARMS AND COSTS

The greatest potential benefits of screening asymptomatic patients for chlamydial infections are the prevention of complications, especially infertility and perinatal complications, and the prevention of disease spread. There is no evidence that screening of the general population for chlamydial infections leads to a reduction in complications, and screening may increase costs. However, there is evidence that annual screening of selected high-risk groups and of pregnant women during the first trimester is beneficial in preventing symptoms and reducing the overall cost resulting from infection.

RECOMMENDATIONS

There is fair evidence to support screening and treatment of pregnant women during the first trimester (grade B recommendation) as well as annual screening and treatment of high-risk groups (sexually active women less than 25 years of age, men or women with new or multiple sexual partners during the preceding year, women who use nonbarrier contraceptive methods and women who have symptoms of chlamydial infection: cervical friability, mucopurulent cervical discharge or intermenstrual bleeding; grade B recommendation). There is fair evidence to exclude routine screening of the general population (grade D recommendation).

VALIDATION

These recommendations are similar to those of the US Preventive Services Task Force and the US Centers for Disease Control and Prevention, Atlanta.

SPONSOR

These guidelines were developed and endorsed by the Canadian Task Force on the Periodic Health Examination, which is funded by Health Canada and the National Health Canada and the National Health Research and Development Program. The principal author (H.D.D.) was supported in part by the Ontario Ministry of Health and the Canadian Infectious Diseases Society Lilly Fellowship.

Contagious equine metritis

Contagious equine metritis (CEM) is a highly contagious venereal infection of equids caused by Taylorella equigenitalis, a bacterium with fastidious growth requirements. A disease of major international concern, CEM can be the cause of short-term infertility and, very rarely, abortion in mares. Unlike the mare, stallions exposed to T. equigenitalis do not develop clinical signs of disease. CEM is transmitted by direct or indirect venereal contact. The carrier state occurs in the mare and the stallion and carrier animals are frequently the source of infection for new outbreaks of the disease. There are streptomycin-sensitive and -resistant biotypes of T. equigenitalis, and diagnosis is based primarily on culture of the bacterium from its predilection sites in the reproductive tract of the mare and the stallion. Treatment modalities are available for elimination of the carrier state. Prevention and control of CEM is achievable through a comprehensive programme of breeding farm management that includes early detection and treatment of carrier mares and stallions.

The prevalence of sexually transmitted diseases in children and adolescents evaluated for sexual abuse in Cincinnati: rationale for limited STD testing in prepubertal girls

OBJECTIVE

To determine the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, syphilis, and human immunodeficiency virus (HIV) infection in sexually abused children and to develop selective criteria for sexually transmitted disease (STD) testing in these children in our community.

DESIGN

Prospective.

SETTING

University-affiliated children's hospital in Ohio.

PARTICIPANTS

All children evaluated at our hospital for sexual abuse were eligible. Eight hundred fifty-five children were evaluated over a 1-year period. The study included 704 girls and 151 boys. Children ranged in age from 3 weeks to 18 years old.

METHODS AND RESULTS

Standard STD testing (American Academy of Pediatrics recommendations) was defined as serum rapid plasma reagin test, examination for Trichomonas, N gonorrhoeae culture of the throat, rectum, and genitalia and C trachomatis culture of the rectum and genitalia. STD testing in this study was recommended in children with 1) a history of genital discharge or contact with the perpetrator's genitalia, 2) examination findings of genital discharge or trauma, and 3) all adolescents. HIV testing was obtained in children with risk factors for HIV infection, those with contact with a perpetrator with HIV risk factors, or if the family was concerned about HIV acquisition. A total of 423 children were tested for N gonorrhoeae, 415 for C trachomatis, 275 for syphilis, 208 for Trichomonas, and 140 for HIV. Twelve children were determined to have N gonorrhoeae infection, 11 had C trachomatis infection, and four had Trichomonas infection. Overall, the prevalence of STDs in prepubertal girls was 3.2% and 14.6% in pubertal girls. The prevalence of N gonorrhoeae in prepubertal girls with vaginal discharge was 11.1% and 0% in prepubertal girls without discharge (P < .001). C trachomatis infection was diagnosed in 0.8% of prepubertal girls compared with 7.0% of pubertal girls (P < .001). None of the children tested positive for syphilis or HIV and no males had a STD.

CONCLUSIONS

In our community, N gonorrhoeae testing in prepubertal girls can be limited to those with a vaginal discharge on examination unless other risk factors are present. The prevalence C trachomatis and Trichomonas in prepubertal girls is low and may be omitted from routine evaluations. All pubertal girls evaluated for sexual abuse should be tested for STDs because of the high prevalence of asymptomatic infection in this patient population.

[Evaluating polymerase chain reaction for detection of C. trachomatis in urogenital smears]

A total of 222 urogenital specimens were investigated with a commercially available polymerase chain reaction (Amplicor test) for the direct detection of Chlamydia trachomatis. The results were compared with those yielded by the conventional cell culture technique. Using cell culture a urogenital C. trachomatis infection could be detected in 72 of 222 patients. The Amplicor test yielded a positive result in 83. Referred to the detection rate of the Amplicor test and that of the cell culture, sensitivity was 91.2% for the test sensitivity and 79.1% for the cell culture. The specificity of both techniques was 100% when the specimens for which neither both nor either one of the tests gave positive results were considered. In accordance with other studies, this study suggests that tests based on nucleic acid amplification will supersede cell cultures as the gold standard for the detection of C. trachomatis and also become the method of choice in routine diagnosis of urogenital chamydial infections.

[The pathogenesis and prevention of urinary tract infection in women]

Urinary tract infection (UTI) in females occurs significantly more frequently than in males because of specific anatomical and functional features of female urinary system, sequelae of pregnancy, delivery, gynecological diseases. Much controversy still exists as to pathogenesis of UTI and UTI-induced urinary inflammation. We have examined 233 females of different age with UTI and obtained evidence which shows participation of such factors as early and intensive sex, ignorance of sex hygiene, multiple pregnancies, deliveries, abortions, inflammatory gynecological diseases, anogenital infection in its pathogenesis. These factors were registered 2-4 times more frequently in UTI females than in controls without UTI. Bacteriological urinary and genital findings coincide in 80% of cases in terms of an infective agent. This suggests that it is essential to detect urogenital infection in girls and females as early as possible and to treat it adequately with antibacterial and other drugs. The leading role of an ascending urinogenic route in urinary tract infection from local sources in anogenital zone, sexual factor and the absence of relevant hygienic habits proved most contributing to UTI pathogenesis. This concept serves the basis for UTI prevention in females.

A comparative study of the Abbott and Murex enzyme immunoassay, and cell culture in the detection of cervical chlamydial infection in female sex workers in Singapore

Endocervical smears from 200 female sex workers were tested for Chlamydia trachomatis infection using the Abbott and Murex enzyme immunoassay (EIA) kits and the standard cell culture technique to compare the performance of these tests. The Abbott test had a sensitivity, specificity, predictive value of a positive result (PVP) and predictive value of a negative result (PVN) of 83.3%, 97.8%, 78.9% and 98.3% respectively. The corresponding figures for the Murex system were 77.8%, 98.4%, 82.4% and 97.8%; and of the standard culture test were 55.6%, 100% and 95.8%. EIA tests were more sensitive but slightly less specific than cell culture in the detection of Chlamydia trachomatis cervical infection in female sex workers in Singapore.

Sexually transmitted diseases from the tropics. An overview

The tropical ecosystem as related to sexually transmitted diseases and their epidemiology is outlined in this article. The predominance of first-generation bacterial STDs with more florid presentations, together with a back-ground of more covert infections, such as with Chlamydia and human papillomavirus, are noted. Presentations of infections in people returning from the tropics are highlighted, and particular features of the various infections relevant to their tropical origin are discussed. The overview can only hint at the wide diversity of infections and presentations from the tropics and the challenge in both diagnosis and control that they present.

[Infections of the ejaculate by sexually transmissible pathogens]

Certain ejaculate infections can be traced back to sexually transmitted microorganisms, such as Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum and Trichomonas vaginalis. To varying extents, these microorganisms cause such classical genital infections as urethritis, epididymitis and prostatitis as well as subclinical genital tract infections. Several different pathomechanisms are under discussion for infection of the ejaculate: reduction of spermatogenesis resulting from testicular damage, autoimmune processes induced by inflammation, direct influence on the spermatozoal function, disturbances in spermatozoal transport, secretory dysfunction of the male accessory sex glands and leukocytospermia with secondary influence on ejaculate parameters. The relevance of these microorganisms for the localization of the inflammatory process within the genital tract are discussed in detail. Their importance for male fertility is a matter of debate. In particular, the significance of C. trachomatis and U. urealyticum, both of which are detectable in the urethra, is still uncertain and cannot be assessed conclusively. Further information allowing delimitation of an infection resulting from bacterial colonization may be provided, on the one hand, by biochemical markers for an inflammatory reaction and indicators of an immune response in the ejaculate, e.g. PMN elastase, complement C3, or coeruloplasmin, and on the other hand, by secretion markers such as alpha-glucosidase, PSA and phosphatase. Whether the assessment of these markers and indicators can help to clarify the inflammatory origin of infertility in individual cases remains doubtful.

Diagnosis of bovine venereal campylobacteriosis by ELISA

An enzyme-linked immunosorbent assay (ELISA) measuring IgA antibodies in the vaginal mucus was used to diagnose bovine venereal campylobacteriosis in 241 herds with infertility and abortions. The presence of the disease was confirmed on 84 farms (34.8%) and it was suspected on a further 27 farms (11.2%). The specificity of the ELISA was found to be 98.5% but in the absence of a reliable comparative test sensitivity can not be estimated. Vaccination against campylobacteriosis will not interfere with the IgA ELISA because only IgG is present in the vaginal mucus of vaccinates. Because of the possibility of false reactions caused by antibody fluctuations in individual cattle, the ELISA is best used as a herd test. It appears that at present the vaginal mucus IgA ELISA is the test of choice for the diagnosis of bovine venereal campylobacteriosis.

[Utility of the Papanicolaou smear in the diagnosis of bacterial vaginosis]

In 200 studied patients there was a sensitivity of 49% and specificity of 100%; bacterial vaginosis incidence was 17.7%; the probability of false negatives was 73%. So, Papanicolaou's smear is not an adequate method for bacterial vaginosis diagnosis, but the negative result, excludes the possibility of disease.

Isolation of Chlamydia trachomatis among women with symptoms of lower genital tract infection

Isolation of chlamydia trachomatis from the endocervix using cyclohexamide-treated McCoy cells were done in order to estimate the prevalence rate of its infection among gynecologic out patients who had symptoms and/or signs of lower genital tract infection. There were 498 patients from May 1989 to July 1990. Eighty-six per cent of these patients were 25 years old or older. Most of them (63%) were agricultural employees. Ninety-three per cent were married and 78 per cent had less than or equal to seven yrs of education. Of 476 specimens, isolation rate of C. trachomatis was 7.8 per cent. Other infectious agents isolated by culture were Niesseria gonorrhea 4.8 per cent (24/497), Candida albicans 15.5 per cent (77/498) and Gardnerella vaginalis 6.08 per cent (303/498). Direct microscopy identified 9.4 per cent (32/380) of Trichomonas vaginalis. Multiple logistic regression analysis was able to identify four significant risk factors independently associated with isolation of C. trachomatis. These factors were N. gonorrheal cervicitis (odds ratio = 5.7, 95%, CI = 1.9, 17.0); age less than 25 yrs (odds ratio = 3.3, 95%, CI = 1.5, 7.4); G. vaginalis vaginitis (odds ratio = 3.0, 95%, CI = 1.3, 7.1) and purulent vaginal discharge (odds ratio = 2.5, 95%, CI = 1.5, 5.5).

Selective screening for Chlamydia trachomatis infection in a primary care population of women

The authors used cell cultures to assess the prevalence of cervical infection caused by Chlamydia trachomatis in a population-based sample of nonpregnant women aged 15 to 34 years who attended two primary care clinics at Group Health Cooperative of Puget Sound, Seattle, Washington, between January 1, 1988, and June 30, 1989. C. trachomatis was isolated from 67 of 1,804 women (3.7%), including 13% of those who were less than 20 years of age. Seven patient characteristics were independently predictive of chlamydial infection by stepwise multivariate logistic regression analysis: being unmarried, examination showing cervical ectopy, black race, douching, nulliparity, age of 24 years or less, and intercourse with two or more partners within the preceding year. Testing all women who had a score of 5 or more (28% of women) on a weighted index based on risk factors would detect 77% of all infections with a positive predictive value of 9%. These results suggest that it should be feasible to develop a risk factor-based program to screen for cervical infection with C. trachomatis in populations where its prevalence is low.

[The concept of the pathogenesis of chronic prostatitis]

The examination covered 4250 males (mean age 23,8 years) suffering from acute and chronic urethritides of various origin. In the chronic course of nongonococcal urethritis chronic prostatis (CP) occurred in 44.1-59.5% of the patients. In short-term nongonococcal urethritides CP was registered 3-4 times more rarely, in acute gonorrhea 40 time more rarely compared to chronic disease. Out of 128 males aged 17-24 free of urological diseases CP was detected in 20.3% of the examinees. CP 150 sufferers aged 19-61 had chlamydia in the urethra in 41.6% of cases. It is suggested that urethral infection can contribute to the onset of CP or add to prostatitis of another origin. It may also aggravate the run of noninfectious prostatitis.