HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis

The primate vaginal microbiome: comparative context and implications for human health and disease

The primate body hosts trillions of microbes. Interactions between primate hosts and these microbes profoundly affect primate physiology, reproduction, health, survival, and ultimately, evolution. It is increasingly clear that primate health cannot be understood fully without knowledge of host-microbial interactions. Our goals here are to review what is known about microbiomes of the female reproductive tract and to explore several factors that influence variation within individuals, as well as within and between primate species. Much of our knowledge of microbial variation derives from studies of humans, and from microbes located in nonreproductive regions (e.g., the gut). We review work suggesting that the vaginal microbiota affects female health, fecundity, and pregnancy outcomes, demonstrating the selective potential for these agents. We explore the factors that correlate with microbial variation within species. Initial colonization by microbes depends on the manner of birth; most microbial variation is structured by estrogen levels that change with age (i.e., at puberty and menopause) and through the menstrual cycle. Microbial communities vary by location within the vagina and can depend on the sampling methods used (e.g., swab, lavage, or pap smear). Interindividual differences also exist, and while this variation is not completely understood, evidence points more to differences in estrogen levels, rather than differences in external physical environment. When comparing across species, reproductive-age humans show distinct microbial communities, generally dominated by Lactobacillus, unlike other primates. We develop evolutionary hypotheses to explain the marked differences in microbial communities. While much remains to be done to test these hypotheses, we argue that the ample variation in primate mating and reproductive behavior offers excellent opportunities to evaluate host-microbe coevolution and adaptation.

The burden of bacterial vaginosis: women's experience of the physical, emotional, sexual and social impact of living with recurrent bacterial vaginosis

BACKGROUND

Bacterial vaginosis is a common vaginal infection, causing an abnormal vaginal discharge and/or odour in up to 50% of sufferers. Recurrence is common following recommended treatment. There are limited data on women's experience of bacterial vaginosis, and the impact on their self-esteem, sexual relationships and quality of life. The aim of this study was to explore the experiences and impact of recurrent bacterial vaginosis on women.

METHODS

A social constructionist approach was chosen as the framework for the study. Thirty five women with male and/or female partners participated in semi-structured interviews face-to-face or by telephone about their experience of recurrent bacterial vaginosis.

RESULTS

Recurrent bacterial vaginosis impacted on women to varying degrees, with some women reporting it had little impact on their lives but most reporting it had a moderate to severe impact. The degree to which it impacted on women physically, emotionally, sexually and socially often depended on the frequency of episodes and severity of symptoms. Women commonly reported that symptoms of bacterial vaginosis made them feel embarrassed, ashamed, 'dirty' and very concerned others may detect their malodour and abnormal discharge. The biggest impact of recurrent bacterial vaginosis was on women's self-esteem and sex lives, with women regularly avoiding sexual activity, in particular oral sex, as they were too embarrassed and self-conscious of their symptoms to engage in these activities. Women often felt confused about why they were experiencing recurrent bacterial vaginosis and frustrated at their lack of control over recurrence.

CONCLUSION

Women's experience of recurrent bacterial vaginosis varied broadly and significantly in this study. Some women reported little impact on their lives but most reported a moderate to severe impact, mainly on their self-esteem and sex life. Further support and acknowledgement of these impacts are required when managing women with recurrent bacterial vaginosis.

Vaginal concentrations of lactic acid potently inactivate HIV

OBJECTIVES

When Lactobacillus spp. dominate the vaginal microbiota of women of reproductive age they acidify the vagina to pH <4.0 by producing ∼1% lactic acid in a nearly racemic mixture of d- and l-isomers. We determined the HIV virucidal activity of racemic lactic acid, and its d- and l-isomers, compared with acetic acid and acidity alone (by the addition of HCl).

METHODS

HIV-1 and HIV-2 were transiently treated with acids in the absence or presence of human genital secretions at 37°C for different time intervals, then immediately neutralized and residual infectivity determined in the TZM-bl reporter cell line.

RESULTS

l-lactic acid at 0.3% (w/w) was 17-fold more potent than d-lactic acid in inactivating HIVBa-L. Complete inactivation of different HIV-1 subtypes and HIV-2 was achieved with ≥0.4% (w/w) l-lactic acid. At a typical vaginal pH of 3.8, l-lactic acid at 1% (w/w) more potently and rapidly inactivated HIVBa-L and HIV-1 transmitter/founder strains compared with 1% (w/w) acetic acid and with acidity alone, all adjusted to pH 3.8. A final concentration of 1% (w/w) l-lactic acid maximally inactivated HIVBa-L in the presence of cervicovaginal secretions and seminal plasma. The anti-HIV activity of l-lactic acid was pH dependent, being abrogated at neutral pH, indicating that its virucidal activity is mediated by protonated lactic acid and not the lactate anion.

CONCLUSIONS

l-lactic acid at physiological concentrations demonstrates potent HIV virucidal activity distinct from acidity alone and greater than acetic acid, suggesting a protective role in the sexual transmission of HIV.

Dectin-1/TLR2 and NOD2 agonists render dendritic cells susceptible to infection by X4-using HIV-1 and promote cis-infection of CD4(+) T cells

HIV-1 pathogenesis is intimately linked with microbial infections and innate immunity during all stages of the disease. While the impact of microbial-derived products in transmission of R5-using virus to CD4⁺ T cells by dendritic cells (DCs) has been addressed before, very limited data are available on the effect of such compounds on DC-mediated dissemination of X4-tropic variant. Here, we provide evidence that treatment of DCs with dectin-1/TLR2 and NOD2 ligands increases cis-infection of autologous CD4⁺ T cells by X4-using virus. This phenomenon is most likely associated with an enhanced permissiveness of DCs to productive infection with X4 virus, which is linked to increased surface expression of CXCR4 and the acquisition of a maturation profile by DCs. The ensuing DC maturation enhances susceptibility of CD4⁺ T cells to productive infection with HIV-1. This study highlights the crucial role of DCs at different stages of HIV-1 infection and particularly in spreading of viral strains displaying a X4 phenotype.

Bacterial vaginosis and risk for Trichomonas vaginalis infection: a longitudinal analysis

BACKGROUND

Bacterial vaginosis (BV) and Trichomonas vaginalis (TV) have been estimated to affect one-quarter to one-third of sexually active women worldwide, and are often found concurrently. Few studies have examined this relationship longitudinally to better understand the direction and temporality of this association.

METHODS

Between 2005 and 2006, a cohort of 853 young, sexually active women was followed in Mysore, India; participants were interviewed and tested for BV and TV at baseline, and at 3- and 6-month visit. Generalized estimating equations were used to estimate how changes in vaginal flora between consecutive visits-as defined by Nugent diagnostic criteria for BV-were related to the risk of TV infection at the latter visit, adjusted for sociodemographic and behavioral covariates. Treatment was offered to women with TV and/or symptomatic BV.

RESULTS

After adjustment for covariates, participants with abnormal vaginal flora at 2 consecutive visits had 9 times higher risk of TV (95% CI: 4.1, 20.0) at the latter visit, relative to those with persistently normal flora. An increased risk of TV was also observed for participants whose flora status changed from normal to abnormal (adjusted risk ratio: 7.11, 95% CI: 2.8, 18.2) and from abnormal to normal (adjusted risk ratio: 4.50, 95% CI: 1.7, 11.8).

CONCLUSIONS

Women experiencing abnormal flora during a 3-month span appear to have significantly increased risk of acquiring TV infection. Women of reproductive age in low-resource settings found to have abnormal vaginal flora should be assessed for TV.

Behavioural and medical predictors of bacterial vaginosis recurrence among female sex workers: longitudinal analysis from a randomized controlled trial

Background

Data 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.

Methods

Trial’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.

Results

440 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.

Conclusion

This 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 registration

Trial registration: NCT00153777

Interaction between endogenous bacterial flora and latent HIV infection

Human commensal bacteria do not normally cause any diseases. However, in certain pathological conditions, they exhibit a number of curious behaviors. In HIV infection, these bacteria exhibit bidirectional relationships: whereas they cause opportunistic infections based on immunological deterioration, they also augment HIV replication, in particular, viral replication from latently infected cells, which is attributable to the effect of butyric acid produced by certain anaerobic bacteria by modifying the state of chromatin. Here, we review recent evidence supporting the contributory role of such endogenous microbes in disrupting HIV latency and its potential link to the clinical progression of AIDS.

The anti-HIV microbicide candidate RC-101 inhibits pathogenic vaginal bacteria without harming endogenous flora or mucosa

PROBLEM

Vaginal microbicides represent a promising approach for preventing heterosexual HIV transmission. However, preclinical evaluation should be conducted to ensure that microbicides will be safe for human cells and healthy microflora of the female reproductive tract. One microbicide candidate, RC-101, has been effective and well tolerated in preliminary cell culture and macaque models. However, the effect of RC-101 on primary vaginal tissues and resident vaginal microflora requires further evaluation.

METHOD OF STUDY

We treated primary vaginal tissues and vaginal bacteria, both pathogenic and commensal, with RC-101 to investigate effects of this microbicide.

RESULTS

RC-101 was well tolerated by host tissues, and also by commensal vaginal bacteria. Simultaneously, pathogenic vaginal bacteria, which are known to increase susceptibility to HIV acquisition, were inhibited by RC-101.

CONCLUSIONS

By establishing vaginal microflora, the specific antibacterial activity of RC-101 may provide a dual mechanism of HIV protection. These findings support advancement of RC-101 to clinical trials.

Sialidase activity in aerobic vaginitis is equal to levels during bacterial vaginosis

OBJECTIVE

To evaluate levels of proinflammatory cytokines and sialidase activity in aerobic vaginitis (AV) in relation to normal vaginal flora and bacterial vaginosis (BV).

STUDY DESIGN

In this cross-sectional study, a total of 682 consecutive non-pregnant women attending the gynecology service were assessed and 408 women were included. Vaginal rinsing samples were collected from 223 women with microscopic finding of BV (n=98), aerobic vaginitis (n=25) and normal flora (n=100). Samples were tested for interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor (TNF)-α, and sialidase activity.

RESULTS

Compared to women with normal flora, vaginal levels of IL-1β were highly increased in both BV and AV (p<0.0001). Significantly higher vaginal IL-6 was detected in AV (p<0.0001) but not in BV, in relation to normal flora. Women with AV also presented increased IL-8 levels (p<0.001), while those with BV presented levels similar to normal flora. Sialidase was increased in BV and AV compared with the normal group (p<0.0001) but no difference in sialidase activity was observed between BV and AV.

CONCLUSION

A more intense inflammatory host response occurs for AV than for BV when compared with normal flora. Furthermore, the increased sialidase activity in AV and BV indicates that both abnormal vaginal flora types can be harmful to the maintenance of a healthy vaginal environment.

Direct questioning is more effective than patient-initiated report for the detection of sexually transmitted infections in a primary care HIV clinic in Western Kenya

In resource-limited settings, detection of sexually transmitted infections (STIs) often relies on self-reported symptoms to initiate management. We found self-report demonstrated poor sensitivity for STI detection. Adding clinician-initiated questions about symptoms improved detection rates. Vaginal examination further increased sensitivity. Including clinician-initiated screening in resource-limited settings would improve management of treatable STIs.

Alcohol use, mycoplasma genitalium, and other STIs associated With HIV incidence among women at high risk in Kampala, Uganda

BACKGROUND

In 2008, the first clinic for women involved in high-risk sexual behavior was established in Kampala, offering targeted HIV prevention. This article describes rates, determinants, and trends of HIV incidence over 3 years.

METHODS

A total of 1027 women at high risk were enrolled into a closed cohort. At 3-monthly visits, data were collected on sociodemographic variables and risk behavior; biological samples were tested for HIV and other reproductive tract infections/sexually transmitted infections (RTI/STIs). Hazard ratios for HIV incidence were estimated using Cox proportional hazards regression among the 646 women HIV negative at enrolment.

RESULTS

HIV incidence was 3.66/100 person-years (pyr) and declined from 6.80/100 pyr in the first calendar year to 2.24/100 pyr and 2.53/100 pyr in the following years (P trend = 0.003). Sociodemographic and behavioral factors independently associated with HIV incidence were younger age, younger age at first sex, alcohol use (including frequency of use and binge drinking), number of paying clients in the past month, inconsistent condom use with clients, and not being pregnant. HIV incidence was also independently associated with Mycoplasma genitalium infection at enrolment [adjusted hazard ratio (aHR) = 2.28, 95% confidence interval (CI): 1.15 to 4.52] and with Neisseria gonorrhoeae (aHR = 5.91, 95% CI: 3.04 to 11.49) and Trichomonas vaginalis infections at the most recent visit (aHR = 2.72, 95% CI: 1.27 to 5.84). The population attributable fractions of HIV incidence for alcohol use was 63.5% (95% CI: 6.5 to 85.8) and for treatable RTI/STIs was 70.0% (95% CI: 18.8 to 87.5).

CONCLUSIONS

Alcohol use and STIs remain important risk factors for HIV acquisition, which call for more intensive control measures in women at high risk. Further longitudinal studies are needed to confirm the association between M. genitalium and HIV acquisition.

In captive rhesus macaques, cervicovaginal inflammation is common but not associated with the stable polymicrobial microbiome

Vaginal inoculation of rhesus macaques (RM) with simian immunodeficiency virus (SIV) has been used to study the biology of HIV transmission. Although the results of vaginal SIV transmission experiments could be affected by vaginal inflammation, studies to date have been conducted without regard to levels of pre-existing genital inflammation present in RM. We collected cevicovaginal secretions (CVS) from 33–36 RM during the mid menstrual cycle (day 10–20) at 2 time points approximately 8 months apart and characterized the mRNA and protein levels of inflammatory cytokines, chemokines and interferon-stimulated genes. There was extreme variability in the levels of inflammatory mediators (IFN-α, IFN-γ, IL-6, TNF, IL-1b, IP-10, MIG, IL-12 and IL-17). In most animals, the mRNA levels of the inflammatory mediators were similar in the 2 CVS samples collected 8 months apart, suggesting that genital inflammation is stable in a subset of captive female RM. At both time points the cervicovaginal microbiota had low levels of Lactobacillus and was relatively diverse with an average of 13 genera in the samples from the first time point (median 13, range 7–21) and an average of 11.5 genera in the samples from the second time point (median 11, range 5–20). Many of the macaques had similar microbiota in the samples collected 8 months apart. However, we found no correlation between specific bacterial genera and the mRNA or protein levels of the inflammatory mediators in the genital tract of RM in this study. It seems likely that results of published vaginal SIV transmission experiments in RM have been influenced by pre-existing inflammation in the animals used for the experiments.

Bacterial colonization and beta defensins in the female genital tract in HIV infection

Beta defensins are antimicrobial peptides that serve to protect the host from microbial invasion at skin and mucosal surfaces. Here we explore the relationships among beta defensin levels, total bacterial colonization, and colonization by bacterial vaginosis (BV)-related bacteria and lactobacilli in the female genital tract in HIV infected women and healthy controls. Cervicovaginal lavage (CVL) samples were obtained from 30 HIV-infected women and 36 uninfected controls. Quantitative PCR assays were used to measure DNA levels of bacterial 16S ribosomal DNA (reflective of total bacterial load), and levels of three BV-related bacteria, three Lactobacillus species (L. crispatus, L. iners and L. jensenii), and total Lactobacillus levels in CVL. Levels of human beta defensins (hBD-2 and hBD-3) were quantified by ELISA. In viremic HIV+ donors, we found that CVL levels of bacterial 16S rDNA were significantly increased, and inversely correlated with peripheral CD4+ T cell counts in HIV+ women, and inversely correlated with age in both HIV+ women and controls. Although CVL DNA levels of BV-associated bacteria tended to be increased, and CVL levels of Lactobacillus DNAs tended to be decreased in HIV+ donors, none of these differences was significant. CVL levels of hBD-2 and hBD-3 were correlated and were not different in HIV+ women and controls. However, significant positive correlations between hBD-3 levels and total bacterial DNA levels in controls were not demonstrable in HIV+ women; the significant positive correlations of hBD2 or hBD-3 and three Lactobacillus species in controls were also not demonstrable in HIV+ women. These results suggest that HIV infection is associated with impaired regulation of innate defenses at mucosal sites.

Inhibition of HIV and HSV infection by vaginal lactobacilli in vitro and in vivo

BACKGROUND AND THE PURPOSE OF THE STUDY

The cervico-vaginal mucosa which is populated with microflora (mostly includes lactobacilli) is the portal of entry for sexually transmitted pathogens.

METHODS

The in vitro anti-viral effect of vaginal and non-vaginal lactobacillus was evaluated using single cycle HIV-1 replication and HSV-2 plaque reduction assays. The XTT proliferation assay was used to monitor the cellular toxicity. The in vivo anti-HSV-1 activity was evaluated in BALB/c mouse model by monitoring skin lesion and immune response development.

RESULTS AND MAJOR CONCLUSION

DMEM culture supernatant of L. Gasseri and L. fermentum (PH 7.3) did not show toxic effect but inhibited 50% of HIV replication at 12 and 31% concentrations, respectively. Co-culture of L. gasseri (1000 CFU/ target cell) showed mild cytotoxicity but inhibited 68% of HIV replication. The supernatant of L. crispatus inhibited 50% of HSV replication at 4% and also co-culture of L. gasseri, L. rhamnosus and L. crispatus revokes almost all of the HSV multiplication. Culture supernatants of L. gasseri and L. crispatus had significant virucidal effect against the HIV and HSV and inhibited HSV infection in a stage before viral entry to the target cells. Alive L. gasseri cells showed high potential for inhibiting HSV-1 infection in vivo condition. Current data indicates that lactobacilli supernatant encompasses components with neutralizing activity against HIV and HSV and it would be a determinant factor for viral diseases transmission and promising lead for anti-viral probiotic design.

Microbial interaction between HIV-1 and anaerobic bacteria producing butyric acid: its potential implication in AIDS progression

Microbial coinfection has great impact on the course of disease progression of HIV-1 and the development of AIDS-related deaths. In fact, progression of AIDS development is more rapid in individuals with concomitant infections. Although it is well known that immunosuppression due to HIV-1 infection leads to AIDS-associated opportunistic infections, it has also become apparent that opportunistic infection often promotes the disease progression of HIV-1 infection by enhancing viral transmission or replication, or by modulating host immune responses. We have focused on such microbial interaction between HIV-1 and butyrate-producing anaerobic bacteria and explored the effects of these bacterial culture supernatants containing butyric acid in upregulating HIV-1 gene expression and thus inducing viral replication from the latently infected cells. Since butyric acid inhibits histone deacetylases, these findings suggest that the HIV latency is maintained in ‘recessive’ chromatin, where histone proteins are largely deacetylated, and that concomitant infection of butyrate-producing bacteria could obviously be a risk factor for HIV-1 reactivation in infected individuals, and might contribute to AIDS progression. Moreover, it is possible that therapeutic elimination of such bacterial infection could conceivably prevent the clinical development of AIDS and its epidemiological transmission. Widespread epidemiological surveys are warranted in order to elucidate the role of concomitant infection of such bacteria.

Poly (4-styrenesulfonic acid-co-maleic acid) is an entry inhibitor against both HIV-1 and HSV infections - potential as a dual functional microbicide

Genital herpes is one of the most prevalent sexually transmitted diseases (STD) caused by herpes simplex viruses type 1 and 2 (HSV-1 and -2). HSV is considered as a major risk factor in human immunodeficiency virus type-1 (HIV-1) infection and rapid progression to acquired immunodeficiency syndrome (AIDS). Here, we reported the finding of a polymer of styrenesulfonic acid and maleic acid (PSM) which exhibited antiviral activity with low cytotoxicity. PSM exhibited in vitro inhibitory activity against HIV-1 pseudovirus and HSV-1 and -2. In vivo efficacy of PSM against HSV-2 (G) was also investigated. We found that both 1% and 5% PSM gels protected mice from HSV-2 vaginal infection and disease progression significantly. Mechanistic analysis demonstrated that PSM was likely an entry inhibitor that disrupted viral attachment to the target cells. In particular, PSM disrupted gp120 binding to CD4 by interacting with the gp120 V3-loop and the CD4-binding site. The in vitro cytotoxicity studies showed that PSM did not stimulate NF-κB activation and up-regulation of proinflammatory cytokine IL-1β and IL-8 in vaginal epithelial cells. In addition, PSM also showed low adverse effect on the growth of vaginal Lactobacillus strains. PSM is, therefore, a novel viral entry inhibitor and a potential microbicide candidate against both HIV-1 and HSV.

Reactivation of latent HIV-1 by a wide variety of butyric acid-producing bacteria

Latently infected cells harbor human immunodeficiency virus type 1 (HIV-1) proviral DNA copies integrated in heterochromatin, allowing persistence of transcriptionally silent proviruses. It is widely accepted that hypoacetylation of histone proteins by histone deacetylases (HDACs) is involved in maintaining the HIV-1 latency by repressing viral transcription. HIV-1 replication can be induced from latently infected cells by environmental factors, such as inflammation and co-infection with other microbes. It is known that a bacterial metabolite butyric acid inhibits catalytic action of HDAC and induces transcription of silenced genes including HIV-1 provirus. There are a number of such bacteria in gut, vaginal, and oral cavities that produce butyric acid during their anaerobic glycolysis. Since these organs are known to be the major site of HIV-1 transmission and its replication, we explored a possibility that explosive viral replication in these organs could be ascribable to butyric acid produced from anaerobic resident bacteria. In this study, we demonstrate that the culture supernatant of various bacteria producing butyric acid could greatly reactivate the latently-infected HIV-1. These bacteria include Fusobacterium nucleatum (commonly present in oral cavity, and gut), Clostridium cochlearium, Eubacterium multiforme (gut), and Anaerococcus tetradius (vagina). We also clarified that butyric acid in these culture supernatants could induce histone acetylation and HIV-1 replication by inhibiting HDAC. Our observations indicate that butyric acid-producing bacteria could be involved in AIDS progression by reactivating the latent HIV provirus and, subsequently, by eliminating such bacterial infection may contribute to the prevention of the AIDS development and transmission.

Vaginal microbiome: rethinking health and disease

Vaginal microbiota form a mutually beneficial relationship with their host and have a major impact on health and disease. In recent years our understanding of vaginal bacterial community composition and structure has significantly broadened as a result of investigators using cultivation-independent methods based on the analysis of 16S ribosomal RNA (rRNA) gene sequences. In asymptomatic, otherwise healthy women, several kinds of vaginal microbiota exist, the majority often dominated by species of Lactobacillus, while others are composed of a diverse array of anaerobic microorganisms. Bacterial vaginosis is the most common vaginal condition and is vaguely characterized as the disruption of the equilibrium of the normal vaginal microbiota. A better understanding of normal and healthy vaginal ecosystems that is based on their true function and not simply on their composition would help better define health and further improve disease diagnostics as well as the development of more personalized regimens to promote health and treat diseases.

Live-attenuated lentivirus immunization modulates innate immunity and inflammation while protecting rhesus macaques from vaginal simian immunodeficiency virus challenge

Immunization with attenuated lentiviruses is the only reliable method of protecting rhesus macaques (RM) from vaginal challenge with pathogenic simian immunodeficiency virus (SIV). CD8(+) lymphocyte depletion prior to SIVmac239 vaginal challenge demonstrated that a modest, Gag-specific CD8(+) T cell response induced by immunization with simian-human immunodeficiency virus 89.6 (SHIV89.6) protects RM. Although CD8(+) T cells are required for protection, there is no anamnestic expansion of SIV-specific CD8(+) T cells in any tissues except the vagina after challenge. Further, SHIV immunization increased the number of viral target cells in the vagina and cervix, suggesting that the ratio of target cells to antiviral CD8(+) T cells was not a determinant of protection. We hypothesized that persistent replication of the attenuated vaccine virus modulates inflammatory responses and limits T cell activation and expansion by inducing immunoregulatory T cell populations. We found that attenuated SHIV infection decreased the number of circulating plasmacytoid dendritic cells, suppressed T cell activation, decreased mRNA levels of proinflammatory mediators, and increased mRNA levels of immunoregulatory molecules. Three days after SIV vaginal challenge, SHIV-immunized RM had significantly more T regulatory cells in the vagina than the unimmunized RM. By day 14 postchallenge, immune activation and inflammation were characteristic of unimmunized RM but were minimal in SHIV-immunized RM. Thus, a modest vaccine-induced CD8(+) T cell response in the context of immunoregulatory suppression of T cell activation may protect against vaginal HIV transmission.

Selective impact of HIV disease progression on the innate immune system in the human female reproductive tract

BACKGROUND

We have previously demonstrated intrinsic anti-HIV activity in cervicovaginal lavage (CVL) from HIV-infected women with high CD4 counts and not on antiretroviral therapy. However, the impact of HIV disease progression on CVL innate immune responses has not been delineated.

METHODS

CVL from 57 HIV-infected women not on antiretroviral therapy were collected by washing the cervicovaginal area with 10 ml of sterile normal saline. We characterized subject HIV disease progression by CD4 count strata: >500 cells/µl, 200-500 cells/µl, or <200 cells/µl of blood. To assess CVL anti-HIV activity, we incubated TZM-bl cells with HIV plus or minus CVL. Antimicrobials, cytokines, chemokines and anti-gp160 HIV IgG antibodies were measured by ELISA and Luminex.

RESULTS

CVL exhibited broad anti-HIV activity against multiple laboratory-adapted and transmitted/founder (T/F) viruses, with anti-HIV activity ranging from 0 to 100% showing wide variation between viral strains. Although there was broad CVL inhibition of most both laboratory-adapted and T/F virus strains, there was practically no inhibition of T/F strain RHPA.c, which was isolated from a woman newly infected via heterosexual intercourse. HIV disease progression, measured by declining CD4 T cell counts, resulted in a selective reduction in intrinsic anti-HIV activity in CVL that paralleled CVL decreases in human beta-defensin 2 and increases in Elafin and secretory leukocyte protease inhibitor. HIV disease progress predicted decreased CVL anti-HIV activity against both laboratory-adapted and T/F strains of HIV. Anti-HIV activity exhibited close associations with CVL levels of fourteen cytokines and chemokines.

CONCLUSIONS

Amid a multifaceted immune defense against HIV-1 and other sexually transmitted pathogens, HIV disease progression is associated with selective disturbances in both CVL anti-HIV activity and specific innate immune defenses in the human female reproductive tract (FRT). Overall, these studies indicate that innate immune protection in the FRT is compromised as women progress to AIDS.

The role of bacterial vaginosis and trichomonas in HIV transmission across the female genital tract

Bacterial vaginosis (BV) and Trichomonas vaginalis (TV) infections are both very common and are associated with increased risk of sexual transmission of HIV. There are several mechanisms by which BV and TV could affect susceptibility including inducing pro-inflammatory cytokines and disrupting mucosal barrier function. This review highlights recent advances in our understanding of how these genital conditions lead to an increased risk of HIV infection in women.

Prevalence of bacterial vaginosis and its risk factors in HIV/AIDS patients with abnormal vaginal discharge

OBJECTIVE

To determine the prevalence of bacterial vaginosis in the HIV/AIDS patients of primary health care clinics in Jos Plateau state, Nigeria.

METHODS

Female genital swabs were collected from primary health care centers, Jos and analyzed by microscopy, culture, etc. in Jos University Teaching Hospital from December 2006 to December 2007. Data on epidemiologic indices were collected, using structured interviewer-administered questionnaires.

RESULTS

The incidence of bacterial vaginosis in the study was 28% (n=196/700). Among the HIV/AIDS group, the bacterial vaginosis incidence was 36% (n=126/350), while in the control (non-HIV patients) group, the rate was 20% (70/350) with a statistically significant difference at 95 percent confidence level (P<0.05). HIV/AIDS and non-HIV (control) patients contributed 64% (n=126/196) and 36% (n=70/196), respectively. The risks to bacterial vaginosis included vaginal douching with disinfectant/detergent constituted (60%), poor use of condom 40%, a median age of 26 years, and a median number of 3 sex partners per week.

CONCLUSIONS

There was a significant statistical difference in prevalence of bacterial vaginosis between the HIV/AIDS group and non-HIV(control) group of patients in the study. Risk behaviors that promote the incidence of bacterial vaginosis should be especially paid attention.

The natural antimicrobial peptide subtilosin acts synergistically with glycerol monolaurate, lauric arginate, and ε-poly-L-lysine against bacterial vaginosis-associated pathogens but not human lactobacilli

Subtilosin is a cyclical antimicrobial peptide produced by Bacillus amyloliquefaciens that has antimicrobial activity against the bacterial vaginosis-associated human pathogen Gardnerella vaginalis. The ability of subtilosin to inhibit G. vaginalis alone and in combination with the natural antimicrobial agents glycerol monolaurate (Lauricidin), lauric arginate, and ε-poly-L-lysine was tested using a checkerboard approach. Subtilosin was found to act synergistically with all of the chosen antimicrobials. These promising results indicate that lower concentrations of subtilosin in combination with other compounds could effectively be used to inhibit growth of the pathogen, thereby decreasing the risk of developed antimicrobial resistance. This is the first report on the effects of subtilosin combined with other natural antimicrobials against G. vaginalis.

Bacterial vaginosis associated with increased risk of female-to-male HIV-1 transmission: a prospective cohort analysis among African couples

BACKGROUND

Bacterial vaginosis (BV), a disruption of the normal vaginal flora, has been associated with a 60% increased risk of HIV-1 acquisition in women and higher concentration of HIV-1 RNA in the genital tract of HIV-1-infected women. However, whether BV, which is present in up to half of African HIV-1-infected women, is associated with an increase in HIV-1 transmission to male partners has not been assessed in previous studies.

METHODS AND FINDINGS

We assessed the association between BV on female-to-male HIV-1 transmission risk in a prospective study of 2,236 HIV-1-seropositive women and their HIV-1 uninfected male partners from seven African countries from a randomized placebo-controlled trial that enrolled heterosexual African adults who were seropositive for both HIV-1 and herpes simplex virus (HSV)-2, and their HIV-1-seronegative partners. Participants were followed for up to 24 months; every three months, vaginal swabs were obtained from female partners for Gram stain and male partners were tested for HIV-1. BV and normal vaginal flora were defined as a Nugent score of 7-10 and 0-3, respectively. To reduce misclassification, HIV-1 sequence analysis of viruses from seroconverters and their partners was performed to determine linkage of HIV-1 transmissions. Overall, 50 incident HIV-1 infections occurred in men in which the HIV-1-infected female partner had an evaluable vaginal Gram stain. HIV-1 incidence in men whose HIV-1-infected female partners had BV was 2.91 versus 0.76 per 100 person-years in men whose female partners had normal vaginal flora (hazard ratio 3.62, 95% CI 1.74-7.52). After controlling for sociodemographic factors, sexual behavior, male circumcision, sexually transmitted infections, pregnancy, and plasma HIV-1 RNA levels in female partners, BV was associated with a greater than 3-fold increased risk of female-to-male HIV-1 transmission (adjusted hazard ratio 3.17, 95% CI 1.37-7.33).

CONCLUSIONS

This study identified an association between BV and increased risk of HIV-1 transmission to male partners. Several limitations may affect the generalizability of our results including: all participants underwent couples HIV counseling and testing and enrolled in an HIV-1 prevention trial, and index participants had a baseline CD4 count ≥ 250 cells/mm³ and were HSV-2 seropositive. Given the high prevalence of BV and the association of BV with increased risk of both female HIV-1 acquisition and transmission found in our study, if this association proves to be causal, BV could be responsible for a substantial proportion of new HIV-1 infections in Africa. Normalization of vaginal flora in HIV-1-infected women could mitigate female-to-male HIV-1 transmission.

TRIAL REGISTRATION

ClinicalTrials.com NCT00194519.

Acceptance of self-testing for increased vaginal pH in different subsets of Ugandan women

We assessed the acceptance of self-testing for vaginal pH in 344 Ugandan women in different clinical settings. Women tested themselves by insertion of a gloved finger into the vagina to test vaginal pH and provide a smear on a glass slide. None of the tested women found the test very difficult: 8% found it somewhat difficult, 16% rather easy and 76% very easy to do. Of the 20% who found it difficult to read the test result, more women were attending a family planning clinic or had a higher diploma ( P = 0.001). Pregnant women were least likely to understand of the meaning of the test, while those visiting family planning clinics had the opposite experience. HIV-infected women were most motivated to accept: 95% would be happy to use the test more often if requested, and another 3.5% felt they might be better motivated to do repeat testing after extra explanation. Self-sampling of vaginal pH is well accepted by Ugandan women. Our new method also allows diagnostic work-up by formal microscopy. Before commencing large-scale population screening, unexpected reactions of different subpopulations should be taken into account.

Identification of immune cells by flow cytometry in vaginal lavages from women with vulvovaginitis and normal microflora

PROBLEM

  The extent of the vaginal immune response is not fully determined. The purpose of this study was to evaluate the vaginal immune cells from women with vulvovaginitis (VV).

METHOD OF STUDY

A total of 142 volunteers diagnosed with bacterial vaginosis (BV), vulvovaginal candidiasis (VC), and BV associated with VC or normal microflora were sampled to evaluate the immune cells by flow cytometry. The immune cells were obtained by vaginal lavage and labeled with fluorochrome-conjugated monoclonal antibodies to identify neutrophil granulocytes, macrophages, CD4(+) and CD8(+) T lymphocytes, B lymphocytes, and NK lymphocytes.

RESULTS

Neutrophil granulocytes were present in 84.6% of samples among the leukocyte populations. Considering samples in which neutrophils were present, the mean percentage of neutrophil granulocytes was significantly higher in women with VC than BV and normal microflora and was significantly lower in women with BV than normal microflora. Macrophages and lymphocytes were present in a lower percentage of samples. The mean percentage of CD4(+) T lymphocytes in vaginal lavages was significantly higher in VC and BV compared with women with normal microflora.

CONCLUSIONS

Neutrophils were the predominant leukocytes and were associated with VC and inversely with BV. CD4(+) T lymphocytes were associated with both VC and BV.

Maternal vitamin D, folate, and polyunsaturated fatty acid status and bacterial vaginosis during pregnancy

OBJECTIVE

To investigate associations among serum 25-hydroxy-vitamin D (25-OH-D), folate, omega-6/omega-3 fatty acid ratio and bacterial vaginosis (BV) during pregnancy.

METHODS

Biospecimens and data were derived from a random sample (N = 160) of women from the Nashville Birth Cohort. We compared mean plasma nutrient concentrations for women with and without BV during pregnancy (based on Nugent score ≥7) and assessed the odds of BV for those with 25-OH-D <12 ng/mL, folate <5 ug/L, and omega-6/omega-3 ratio >15.

RESULTS

The mean plasma 25-OH-D was significantly lower among women with BV during pregnancy (18.00±8.14 ng/mL versus 24.34±11.97 ng/mL, P = 0.044). The adjusted odds of BV were significantly increased among pregnant women with 25-OH-D <12 ng/mL (aOR 5.11, 95% CI: 1.19-21.97) and folate <5 ug/L (aOR 7.06, 95% CI: 1.07-54.05).

CONCLUSION

Vitamin D and folate deficiencies were strongly associated with BV (Nugent score ≥7) during pregnancy.

Role of probiotics in urogenital healthcare

Urogenital infections are one of the most common causes for a woman to visit a gynecologist or a urologist. The well-known association between abnormal vaginal microbial flora and its formidable risk in the increased incidence of urinary tract infection underscores the importance of understanding the microbial flora and the efforts needed to maintain it, for ensuring urogenital health. Surprisingly in spite of the increased incidence urogenital infections receive very less attention from the medical fraternity. Growing awareness among people and newer advances in the medical field has brought them into the limelight. The importance of replenishing these depleting commensals with ‘probiotics’ has resurfaced in a big way. As the days go by science and medicines will touch new milestones, which will include probiotics. The value of a probiotics cannot be taken at face value. Probiotics must not be considered a panacea for treating urogenital infections. However, the available data promises that it will be a strong option in improving and maintaining urogenital health.

Short-chain fatty acids induce pro-inflammatory cytokine production alone and in combination with toll-like receptor ligands

PROBLEM

Short-chain fatty acids (SCFAs), produced at relatively high levels by anaerobic bacteria in bacterial vaginosis (BV), are believed to be anti-inflammatory. BV, a common alteration in the genital microbiota associated with increased susceptibility to HIV infection, is characterized by increased levels of both pro-inflammatory cytokines and SCFAs. We investigated how SCFAs alone or together with Toll-like receptor (TLR) ligands affected pro-inflammatory cytokine secretion.

METHOD OF STUDY

Cytokines were measured by ELISA. Flow was used for phenotyping and reactive oxygen species (ROS) measurement.

RESULTS

Short-chain fatty acids, at 20 mM, induced interleukin (IL)-8, IL-6, and IL-1β release, while lower levels (0.02-2 mM) did not induce cytokine secretion. Levels >20 mM were toxic to cells. Interestingly, lower levels of SCFAs significantly enhanced TLR2 ligand- and TLR7 ligand-induced production of IL-8 and TNFα in a time- and dose-dependent manner, but had little effect on lipopolysaccharide-induced cytokine release. SCFAs mediated their effects on pro-inflammatory cytokine production at least in part by inducing the generation of ROS.

CONCLUSION

Our data suggest that SCFAs, especially when combined with specific TLR ligands, contribute to a pro-inflammatory milieu in the lower genital tract and help further our understanding of how BV affects susceptibility to microbial infections.

Lower genital tract infections in HIV-seropositive women in India

OBJECTIVES

The presence of STD facilitates shedding of HIV and increases HIV-1 disease progression, possibly by increasing plasma viremia. Our aim was to study the presence of various associated Sexually transmitted disease/Reproductory tract infections in HIV-seropositive women in India.

MATERIALS AND METHODS

The study included 40 HIV-seropositive women attending the antiretroviral therapy (ART) clinic at Lok Nayak Hospital. An informed consent was taken from all subjects. All cases were subjected to detailed gynecological examination and two types of swabs, i.e., a vaginal swab and a cervical swab were taken for STD/RTIs evaluation. The vaginal swabs were used for preparation of wet mount and KOH mount for diagnosis of trichomoniasis and candidiasis; to make a vaginal smear for Gram staining to diagnose bacterial vaginosis (BV) as per Nugent's criteria; for culture of aerobic bacteria and Candida spp. The cervical swab was used for isolation of Neisseria gonorrhoeae by culture and for detection of Chlamydia trachomatis antigen by Chlamydia microplate enzyme immunoassay kit (BIORAD). All data were analyzed using appropriate statistical tests.

RESULTS

All 40 cases were evaluated for the presence of STD/RTIs associated with HIV infection. The women belonged to the reproductive age group (15-45 years) and majority (40%) of them were para 2. Most of the women (14, 35%) were in World Health Organization (WHO) stage I and maximum number (28, 70%) had their CD4 cell count more than 200 cells/ml. There was no significant correlation between WHO stage of HIV-seropositive women and their CD4 cell count (P=0.092). Out of 40 cases, 15 (37.5%) were on ART with maximum cases (53.3%) in WHO stage III. The duration of ART was more than 6 months in 9 (60%) cases. The most common presenting complaint was vaginal discharge in women with WHO stage II and III and 27.5% women showed vaginitis on per speculum examination. Laboratory tests showed high prevalence of BV (30%), mixed infection (30%), and candidiasis (10%) among HIV-seropositive women (P<0.001 in both). Women with BV were mostly in WHO stage I (38.4%) and stage II (36.3%), while those with mixed infection were mainly in WHO stage III (36.3%) and stage IV (40%).Women with candidiasis were mainly in WHO stage III. C. trachomatis antigen was found only in one subject (prevalence 2.5%). Both WHO stage and CD4 cell count had no significant correlation with presence of BV (P=0.056 and 0.063, respectively) and candidiasis (P=0.492 and 0.530, respectively). Maximum number of patients on ART had mixed infection (53.3%), while most of the patients (36%) not on ART had BV. There was no significant association between duration of ART and the presence of vaginal infections.

CONCLUSIONS

The prevalence of gynecological symptoms and RTIs in HIV-seropositive women is high enough to warrant routine gynecologic evaluation and RTI screening in these patients. However, larger studies and trials are needed to evaluate the effects of ART on these abnormalities as well as to choose the best screening tool in HIV-seropositive women.

Comparative efficacy of probiotic yoghurt and clindamycin in treatment of bacterial vaginosis in pregnant women: a randomized clinical trial

OBJECTIVE

This study was performed to determine the comparative efficacy of probiotic yoghurt and clindamycin in the treatment of bacterial vaginosis in pregnant women in the third trimester.

METHODS AND MATERIALS

This randomized clinical trial was performed as an open-label study. 310 symptomatic patients with BV were recruited. Diagnosis of BV was through Amsel criteria. The patients were randomly assigned to receive either probiotic yoghurt (100 g twice a day/week) or orally administered clindamycin (300 mg twice a day/week).

RESULTS

Ten patients in probiotic group and 9 subjects in clindamycin group had symptom recurrence (p > 0.05). 132 patients in probiotic group and 105 subjects in clindamycin group had pH decrease (p < 0.0001). 140 patients in probiotic group and 141 subjects in clindamycin group had complete symptomatic cure (p > 0.05). Twelve patients in probiotic group and seven subjects in clindamycin group had preterm birth. Nine women in probiotic group and five subjects in clindamycin group had PROM (p > 0.05).

CONCLUSIONS

According to the obtained results, it may be concluded that probiotics would have a good efficacy in the treatment of bacterial vaginosis in pregnancy leading to decreased burden of subsequent preterm birth.

The complex vaginal flora of West African women with bacterial vaginosis

Background

The spectrum of bacteria associated with bacterial vaginosis (BV) has recently expanded through taxonomic changes and the use of molecular methods. These methods have yet to be used in large-scale epidemiological studies in Africa where BV is highly prevalent.

Methods

An analysis of samples obtained during a clinical trial of the management of vaginal discharge in four West African countries. Samples were available from 1555 participants; 843 (54%) had BV. Nucleic acids of 13 bacterial genera or species potentially associated with BV were detected through the polymerase chain reaction.

Results

The associations between various components of the vaginal flora were complex. Excluding Lactobacillus, the other 12 micro-organisms were all associated with each other at the p≤0.001 level. The prevalence of various bacterial genera or species varied according to age, sexual activity and HIV status. In multivariate analysis, the presence of Gardnerella vaginalis, Bifidobacterium, Megasphaera elsdenii, Dialister, Mycoplasma hominis, Leptotrichia, and Prevotella were independently associated with BV as was the absence of Lactobacillus and Peptoniphilus. However, Mobiluncus, Atopobium vaginae, Anaerococcus, and Eggerthella were not independently associated with BV. Unexpectedly, after treatment with a regimen that included either metronidazole or tinidazole, the proportion of patients with a complete resolution of symptoms by day 14 increased with the number of bacterial genera or species present at enrolment.

Conclusions

Numerous bacterial genera or species were strongly associated with each other in a pattern that suggested a symbiotic relationship. BV cases with a simpler flora were less likely to respond to treatment. Overall, the vaginal flora of West African women with BV was reminiscent of that of their counterparts in industrialized countries.

Intravaginal microbial flora by the 16S rRNA gene sequencing

OBJECTIVE

Conventional diagnosis of bacterial vaginosis contains some controversial points. To understand accurately the relationship between clinical stages and the microbiotas, the intravaginal microbial flora was analyzed by the clone library method.

STUDY DESIGN

Vaginal fluid samples from 31 patients were examined. Lactobacillary grade, Nugent score, culture-based method, and clone library analysis using the 16SrRNA gene sequencing were performed and were compared with each other.

RESULTS

Patients were categorized by Lactobacillary grade as I (normal) (n = 6), II (intermediate) (n = 11), and III (bacterial vaginosis) (n = 14). The clone library analysis detected 36 bacterial genera and 60 species from all 31 samples. A principal component analysis of the microbial proportions revealed a novel classification, which suggested the significance of the relative ratio of Lactobacillus iners, Atopobium vaginae and anaerobes in bacterial vaginosis.

CONCLUSION

Clone library analysis in combination with the conventional method provides substantial information for diagnosis of bacterial vaginosis.

[Current knowledge of bacterial vaginosis]

Bacterial vaginosis, earlier termed nonspecific vaginitis (anaerobic vaginosis) because of the absence of recognized pathogens, is most common vaginal syndrome of women of childbearing age affecting 15-30%. This syndrome, whose aetiology and pathogenesis remains unknown, is characterized by significant changes in the vaginal ecosystem. These changes consist of a decrease in the number of lactobacilli and a large increase in the number of anaerobic organisms. The bacteria adhere to desquamated epithelial cells with a distinctive appearance of clue cells The main complaints of women with symptomatic bacterial vaginosis include vaginal discharge and odour. However, a significant number of all women who have bacterial vaginosis deny symptoms. Bacterial vaginosis is associated with a number of gynaecologic and obstetric complications including cervicitis, cervical neoplasia, pelvic inflammatory disease, postoperative infections, and preterm labour.The diagnosis is most frequently made based on vaginal smear stained according to Gram (Nugent scoring method). Metronidazole and clindamycin are the drugs of choice for treatment of women with bacterial vaginosis. Which women should undergo treatment? According to the prevailing attitude, it should include women with symptoms. Symptomatic women with frequent relapses of bacterial vaginosisas, as a rule, have poor response to the applied therapy. To achieve better efficiency in the treatment of such women, it is necessary to have more extensive understanding of all factors in the pathogenesis of the syndrome.

Severity of bacterial vaginosis and the risk of sexually transmitted infection

OBJECTIVE

The purpose of this study was to determine whether the association between bacterial vaginosis (BV) and incident sexually transmitted infection (STI) varies with more extreme BV scores.

STUDY DESIGN

We analyzed the data from 535 women who were enrolled in a randomized trial to promote dual method contraceptive use. Incident STI was defined as any case of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, or pelvic inflammatory disease. BV was defined by Gram stain (Nugent score). STI risk was estimated with the use of proportional hazards regression.

RESULTS

Binary (0-6 vs 7-10) and 3-level (negative 0-3, intermediate 4-6, or BV 7-10) categorizations were not associated with time to STI; however, women with the highest Nugent scores (9-10) had a 2.1-fold increased risk of STI (95% confidence interval, 1.05-4.28), compared with women with normal flora.

CONCLUSION

Nugent score>8 is associated with incident STI. More accurate classification of BV will allow clinicians to identify those women who are at greatest risk of STI.

The laboratory diagnosis of bacterial vaginosis

Bacterial vaginosis (BV) is an extremely common health problem for women. In addition to the troublesome symptoms often associated with a disruption in the balance of vaginal flora, BV is associated with adverse gynecological and pregnancy outcomes. Although not technically a sexually transmitted infection, BV is a sexually associated condition. Diagnostic tests include real-time clinical/microbiological diagnosis, and the current gold standard, the standardized evaluation of morphotypes on Gram stain analysis. The inappropriate use of vaginal culture can be misleading. Future developments into molecular-based diagnostics will be important to further understand this complex endogenous flora disruption.

Co-occurrence of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women

Trichomonas vaginalis (TV) and bacterial vaginosis (BV) were examined among human immunodeficiency virus+ women. The prevalence rates were 28.0% for TV, 51.4% for BV, and 17.5% for TV/BV co-infection. Among human immunodeficiency virus+/TV+ women, the rate of BV was 61.0%. Research is needed to examine how BV affects the clinical course and treatment of T. vaginalis.

Organism diversity between women with and without bacterial vaginosis as determined by polymerase chain reaction denaturing gradient gel electrophoresis and 16S rRNA gene sequence

AIMS

The aim of this study was to characterize the different structures of microbial communities between 20 healthy women and 17 bacterial vaginosis (BV)-positive women of reproductive age using denaturing gradient gel electrophoresis (DGGE).

MATERIAL AND METHODS

Vaginal samples from 17 BV-positive and 20 BV-negative women were subjected to DNA extraction, and amplified with eubacterial 16S rRNA gene-specific primers via polymerase chain reaction. The polymerase chain reaction products were separated using DGGE. Bands were excised, re-amplified, purified and sequenced. DNA sequences were compared with GenBank database. Phylip software packages were used to calculate sequencing data and form a phylogenetic tree to identify the genetic relations for microbiota inhabited in vaginal ecosystems of BV-positive women.

RESULTS

In total, 28 kinds of organisms were detected that comprised BV(+) vagina microbial community, varying from three to nine kinds with an average of 5.71 kinds per woman. Only seven species were detected in BV(-) women, ranging between one and five species with an average of 2.40 species per woman, which was significantly lower than that detected in BV(+) women (t = 7.39, P < 0.001). A strain of Uncultured Lactobacillus sp. clone EHFS1_S05c (29/37; 78.38%) was most commonly presented in both BV-negative and BV-positive women, but the mean proportion of this Lactobacillus sp. strain to the whole microbial population colonized in the vaginal tract of BV(-) women was sharply higher than that calculated from BV(+) women (t = 2.92, P < 0.01).

CONCLUSIONS

The findings indicate further diversity in the category of vaginal microorganisms associated with BV. The presence of Gardnerella vaginalis is not necessary as a sign for gynecologists to determine whether or not a woman is affected by BV.

Innate immunity and inflammatory response to Trichomonas vaginalis and bacterial vaginosis: relationship to HIV acquisition

Most women contract HIV-1 through sexual intercourse with an infected partner. Highly prevalent, unreported and often asymptomatic lower genital tract infections, including bacterial vaginosis (BV) and trichomoniasis (Trichomonas vaginalis- TV), increase a woman's susceptibility to HIV-1 genital infection, given an exposure. A review of the literature from 1989 to the present was conducted. This article will review potential mechanisms by which BV and TV serve as HIV-1-enhancing cofactors including (i) initiation of a clinical or subclinical mucosal inflammatory response, (ii) alteration of innate mucosal immunity, (iii) alteration of normal vaginal microflora and pH, and (iv) weakening or breach of intact cervico-vaginal mucosa. The transmission of HIV-1, in the absence of cofactors, is poorly efficient. Understanding the mechanisms by which these infections enhance HIV-1 acquisition is important to designing effective, safe and evidence-based prevention modalities.

The vaginal microbiome: new information about genital tract flora using molecular based techniques

Vaginal microbiome studies provide information that may change the way we define vaginal flora. Normal flora appears dominated by one or two species of Lactobacillus. Significant numbers of healthy women lack appreciable numbers of vaginal lactobacilli. Bacterial vaginosis (BV) is not a single entity, but instead consists of different bacterial communities or profiles of greater microbial diversity than is evident from cultivation-dependent studies. BV should be considered a syndrome of variable composition that results in different symptoms, phenotypical outcomes, and responses to different antibiotic regimens. This information may help to elucidate the link between BV and infection-related adverse outcomes of pregnancy.

Lactobacillus rhamnosus GR-1 and L. reuteri RC-14 to prevent or cure bacterial vaginosis among women with HIV

OBJECTIVE

To assess, among women with HIV, whether long-term oral Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 supplementation can prevent bacterial vaginosis (BV) and enhance the cure rate of metronidazole among those with BV.

METHODS

A randomized, double-blind, placebo-controlled trial conducted among 65 HIV-infected women with an aberrant microbiota (Nugent score 4-10) who were randomized to receive daily probiotics or placebo for 6 months. Those with BV (Nugent score 7-10) additionally received metronidazole for 10 days (400 mg twice daily).

RESULTS

We did not find an enhanced cure rate of BV among women with HIV treated with adjuvant probiotics to metronidazole treatment. Among women with an intermediate vaginal flora, probiotics tended to increase the probability of a normal vaginal flora (odds ratio 2.4; P=0.1) and significantly increased the probability of a beneficial vaginal pH (odds ratio 3.8; P=0.02) at follow-up.

CONCLUSION

Supplementation of probiotic L. rhamnosus GR-1 and L. reuteri RC-14 did not enhance the cure of BV among women living with HIV, but may prevent the condition among this population.

TRIAL REGISTRATION

NCT00536848.