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

Recurrent Bacterial Vaginosis

Bacterial vaginosis (BV) is a common cause of vaginal discharge in women of childbearing age. In some individuals, it recurs frequently after treatment, frustrating both the patient and the physician. Standard BV treatment--metronidazole or clindamycin, administered either intravaginally or orally--is followed by relapse in approximately 30% of cases, within one month. Our inability to prevent relapse reflects our lack of understanding of how BV originates. BV has been associated with infectious morbidity in obstetrics and gynecology. Recent studies have found it to be a risk factor for HIV spread. These findings increase the need for us to be able to control recurrent BV and reduce its prevalence in the general population.

Lower Genital Tract Infections and HIV in Women

Lower genital tract infections and HIV are major causes of morbidity and mortality among women; thier impact on the US economy amounts to several billion dollars each year. Most lower genital tract infections--and their adverse sequelae, such as pelvic inflammatory disease, ectopic pregnancy, chronic pelvic pain, and increased susceptibility to HIV--are caused by sexually transmitted diseases (STDs). This article reviews recent epidemiologic information relevant to some of the STDs that more commonly affect women, and recent advances in molecular biology, diagnostics, and treatments. Effective, consistent, and proper use of barrier contraception should be encouraged, to decrease the transmission of these infections.

Preliminary safety and acceptability of a carrageenan gel for possible use as a vaginal microbicide

OBJECTIVE

We sought to determine the safety and acceptability of vaginal gel formulation PC-503 among low risk, abstinent women. The active ingredient was 2% pharmaceutical grade lambda carrageenan, a sulphated polymer that is generally recognised as safe by the US Food and Drug Administration.

METHODS

35 women in five sites applied 5 ml of the PC-503 gel vaginally once a day for 7 days while abstaining from sexual intercourse. Visual vaginal examinations were performed on days 1, 4, and 8. STI testing and vaginal pool Gram stain preparations were done on days 1 and 8. Participants were asked about product acceptability.

RESULTS

34 of the 35 women enrolled completed 7 days' use. Following product use, five reported mild symptoms including "bladder fullness," "genital warmth," or discomfort, and lower abdominal pain, and one had moderate pale yellow cervical discharge. Using the Nugent criteria, three women had bacterial vaginosis (BV) before and after use; three had BV before but not after, and two had BV after but not before. Most of the women found PC-503 to be pleasant or neutral in feel and smell and considered extra lubrication to be an advantage; however, one third found it to be messy.

CONCLUSIONS

Vaginal use of PC-503 gel did not cause significant adverse effects in a small number of low risk, sexually abstinent women. Further testing in larger numbers of sexually active women is planned. A smaller volume of gel may be more acceptable to some women.

Levels of vaginal secretory leukocyte protease inhibitor are decreased in women with lower reproductive tract infections

OBJECTIVE

Secretory leukocyte protease inhibitor contributes resistance to primary human immunodeficiency virus infection in the oral cavity. However, the levels of this inhibitor in the genital tract of women with sexually transmitted diseases or vaginitis are not well described. The objective was to determine vaginal inhibitor levels in women with symptomatic and asymptomatic genital infections.

STUDY DESIGN

We tested 207 nonpregnant women for Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Candida species, and bacterial vaginosis by standard methods. A second group of symptom-free pregnant women (N = 231) was also studied. Secretory leukocyte protease inhibitor was measured by enzyme-linked immunosorbent assay, and results were compared by nonparametric methods.

RESULTS

Vaginal levels of secretory leukocyte protease inhibitor in both groups were significantly lower in women with any sexually transmitted disease than in those without infection (P<.0001). Patients with bacterial vaginosis and those with bacterial vaginosis with yeast vaginitis also had decreased levels (P<.025).

CONCLUSIONS

Levels of secretory leukocyte protease inhibitor in vaginal fluid are decreased in women with lower genital tract infection. This may represent a common mechanism of increasing susceptibility to infection with human immunodeficiency virus.

Bacterial vaginosis and Chlamydia trachomatis among pregnant abused and nonabused Hispanic women

OBJECTIVE

To compare the prevalence of bacterial vaginosis (BV) and Chlamydia trachomatis (CT) among abused and nonabused pregnant Hispanic women.

DESIGN

Retrospective audit of charts of 233 pregnant, abused Hispanic women and 468 pregnant, nonabused Hispanic women.

SETTING

Three urban prenatal clinics of a public health department in the southwestern United States.

SAMPLE

The medical records of 701 pregnant Hispanic women.

MAIN OUTCOME MEASURE

Diagnosis of BV and/or CT among abused and nonabused pregnant women.

RESULTS

Combined prevalence of BV and CT was significantly higher for abused women (z score = 2.55; df = 138; p < .05). There was no significant difference between abused and nonabused women for CT alone (z score = .96; df = 33; p < .05); however, prevalence of BV was significantly higher for abused women (z score = 1.99; df = 104; p < .05).

CONCLUSION

In this sample of pregnant Hispanic women prevalence of BV was significantly higher in those who had been abused, indicating the need for targeted screening of all abused pregnant women for BV.

Gynecologic infections in human immunodeficiency virus-infected women

The maturation of the acquired immunodeficiency syndrome epidemic has now claimed more than 12 million women worldwide, the majority in undeveloped countries where human immunodeficiency virus (HIV) and sexually transmitted infections coexist and interact synergistically. Among HIV-infected women, there is excessive morbidity due to sexually transmitted diseases (STDs) and gynecologic disorders. This review summarizes the expanding understanding of vaginal flora, vaginitis, cervicitis, pelvic inflammatory disease, and genital ulcer disease in HIV-infected women. In addition to the altered clinical course, complications, and management difficulties of STDs, some gynecologic infections may influence HIV transmission as well as the vertical transmission of HIV to the newborn. Finally, severe immunodeficiency allows unusual opportunistic pathogens to invade the upper and lower genital tract. Control and prevention of gynecologic infections in HIV-positive and HIV-negative women are key components to preventing further HIV transmission.

Genital tract infections and perinatal transmission of HIV

In areas of the world where genital tract infections (GTIs) are common, the prevalence of HIV and the rate of mother-to-child transmission (MTCT) of HIV are also high. Although observational studies suggested that GTIs are associated with MTCT of HIV, no controlled clinical trial has confirmed this finding. It is likely that GTIs that cause either discharges or ulcers during pregnancy increase perinatal transmission of HIV. Several potential biological mechanisms might facilitate perinatal transmission. For example, chorioamnionitis, increased viral shedding in cervicovaginal secretions, increased HIV acquisition during pregnancy, inflammatory cytokine production, preterm labor, prolonged rupture of membranes, ascending infection, and increased intrapartum infectious secretions are factors that can be associated with GTIs. Several studies have shown that treating clinical conditions associated with inflammation might alter HIV shedding. It is conceivable that preventing ascending infection or reducing exposure of the infant to infectious material during birth could reduce MTCT. This can possibly be achieved by antimicrobial therapy during pregnancy and intrapartum. Such an approach is practical, is less expensive, and has secondary benefits related to prevention of adverse pregnancy outcomes associated with GTIs. Antibiotics might also complement reductions in MTCT of HIV obtained by antiretrovirals given to the mother around the time of delivery. In addition, antibiotics could reduce infectious causes of morbidity and mortality in infant and mother.

Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?

Exclusive breast-feeding is unambiguously the optimal infant feeding practice and is universally promoted in the absence of human immunodeficiency virus (HIV-1). It is associated with reduced morbidity and mortality from diarrheal and respiratory diseases. Recent findings suggest that exclusive breast-feeding may pose less risk of HIV-1 transmission than the more common practice of mixed feeding (i.e., breast-feeding concurrent with the feeding of water, other fluids, and foods), which has important infant feeding policy implications for low-resource settings. This paper reviews the biologic mechanisms associated with exclusive breast-feeding that provide protection against gastrointestinal, respiratory, and atopic diseases, and evaluates the relevance of these mechanisms for HIV-1 transmission. Potential mechanisms include reduction in dietary antigens and enteric pathogens that may maintain integrity of the intestinal mucosal barrier and limit inflammatory responses of the gut mucosa; promotion of beneficial intestinal microflora that may increase resistance to infection and modulate the infant's immune response; alteration in specific antiviral or anti-inflammatory factors in human milk that may modulate maternal hormonal or immunologic status; and maintenance of mammary epithelial integrity that may reduce viral load in breast milk.

Binding of catalase by Gardnerella vaginalis

Previous work has demonstrated that Gardnerella vaginalis can utilize catalase as a sole source of iron. In this study, the interaction between G. vaginalis cells and catalase was investigated. G. vaginalis cells were shown to bind digoxigenin (DIG)-labeled catalase using a solid phase dot blot assay. An increase in catalase binding was observed from cells grown under iron-restrictive conditions. Western blot analysis of G. vaginalis proteins resulted in the detection of a putative catalase-binding protein with an estimated molecular mass of 128 kDa. The 128-kDa catalase-binding protein was not detected from intact G. vaginalis cells treated with trypsin prior to Western blot analysis suggesting this protein may be surface-exposed.

Care of vaginal symptoms among HIV-infected women

OBJECTIVE

Gynecologic disease is common in HIV-infected women. We examine the sociodemographic, clinical, and provider factors associated with the care of women with vaginal symptoms.

METHODS

Women enrolled in the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults, were interviewed between January 1996 and April 1997. Women with vaginal symptoms who sought medical attention were asked, "Did your health care provider examine your vaginal area?" Women were also asked if they received medication for their symptoms.

RESULTS

Among 154 women with vaginal symptoms, 127 sought care for their symptoms. Of those who sought care, 48% saw a gynecologist and 52% sought care from nongynecologists, most often their usual HIV care provider. Women who saw a gynecologist for their symptoms were more likely to have received a pelvic examination (92% versus 76%; p =.06) and vaginal fluid collection (98% versus 88%; p =.06) than those who saw their regular HIV provider. Fifteen percent of women received medication for their symptoms without having a pelvic examination; gynecologists were less likely to prescribe without an examination (8% versus 21%; p =.12).

CONCLUSION

Gynecologists are more likely to provide adequate care of vaginal symptoms among HIV-infected women than nongynecologists who were HIV care providers. This specialty difference is consistent with quality of care studies for other medical conditions, but the potential gynecologic complications of inadequate evaluation and treatment warrants further investigation.

Pattern of sexually transmitted diseases and risk factors among women attending an STD referral clinic in Nairobi, Kenya

BACKGROUND

In Kenya, sexually transmitted disease (STD) clinics care for large numbers of patients with STD-related signs and symptoms. Yet, the etiologic fraction of the different STD pathogens remains to be determined, particularly in women.

GOAL

The aim of the study was to determine the prevalence of STDs and of cervical dysplasia and their risk markers among women attending the STD clinic in Nairobi.

STUDY DESIGN

A cross-section of women were interviewed and examined; samples were taken.

RESULTS

The mean age of 520 women was 26 years, 54% had a stable relationship, 38% were pregnant, 47% had ever used condoms (1% as a method of contraception), 11% reported multiple partners in the previous 3 months, and 32% had a history of STDs. The prevalence of STDs was 29% for HIV type 1, 35% for candidiasis, 25% for trichomoniasis, 16% for bacterial vaginosis, 6% for gonorrhea, 4% for chlamydia, 6% for a positive syphilis serology, 6% for genital warts, 12% for genital ulcers, and 13% for cervical dysplasia. Factors related to sexual behavior, especially the number of sex partners, were associated with several STDs. Gonorrhea, bacterial vaginosis, cervical dysplasia, and genital warts or ulcers were independently associated with HIV infection. Partners of circumcised men had less-prevalent HIV infection.

CONCLUSION

Most women reported low-risk sexual behavior and were likely to be infected by their regular partner. HIV and STD prevention campaigns will not have a significant impact if the transmission between partners is not addressed.

Sexually transmitted infections, adverse pregnancy outcome and neonatal infection

Prevention and treatment of sexually transmitted infections (STIs) in the sexually active population are the main steps to prevent perinatal infection. However, the spread of STIs continues at an astronomical pace despite various attempts at controlling the epidemic. An important reason for this lack of STI control is that a large percentage of infected people go untreated because they have asymptomatic or unrecognized infections. The microbial differential diagnosis of STIs implicated in adverse pregnancy outcome is broad and includes viral, bacterial and protozoal infections. Infertility, ectopic pregnancy, pelvic inflammatory disease, chorioamnionitis, premature rupture of membranes, preterm birth and puerperal sepsis are some of complications seen in women as a result of infection with sexually transmitted pathogens. In addition, STIs may facilitate the acquisition and transmission of HIV. In the fetus or neonate, complications include abnormalities of the major organ systems. Infections in the form of pneumonia or conjunctivitis may also occur. Due to the lack of simple, inexpensive and sensitive point-of-care tests, screening for STIs in pregnancy is not performed routinely.

Vaginal infections in human immunodeficiency virus-infected women

OBJECTIVE

This study was undertaken to compare the frequencies of vaginal infections among human immunodeficiency virus-infected women with those among human immunodeficiency virus-seronegative women.

STUDY DESIGN

Human immunodeficiency virus-seropositive women attending a comprehensive care center for human immunodeficiency virus disease at the outpatient department of an inner-city hospital in Houston underwent rigorous gynecologic evaluation for sexually transmitted diseases, including evidence of vaginal infections such as bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis. Demographic information was collected, as was information regarding disease classification and degree of immunosuppression. Data regarding sexually transmitted diseases, data regarding vaginal infections, and demographic information were collected from a cohort of human immunodeficiency virus-seronegative women attending a sexually transmitted disease and family planning clinic at the same institution. The two groups were compared to determine whether there were any differences between them in the frequencies of sexually transmitted diseases and vaginal infection. Data analysis used the t test for parametric data and the Fisher exact test for nonparametric data where appropriate. P <.05 was considered significant. Statistical analysis was performed with the SAS (SAS Institute, Inc, Cary, NC) statistical software package.

RESULTS

There was no difference in age between the 2 groups. The human immunodeficiency virus-infected group was predominantly African American (80.5%), whereas the human immunodeficiency virus-seronegative control group was more evenly divided between African American women (45.8%) and Latinos (41.7%; P <.0001). Although there was no significant association between HIV infection and sexually transmitted diseases in general, there were significant associations between human immunodeficiency virus infection and bacterial vaginosis (P =.02), vulvovaginal candidiasis (P =.001), and trichomonal vaginitis (P =. 003).

CONCLUSION

Human immunodeficiency virus-infected women had increased frequencies of vaginal infections, including bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis, with respect to human immunodeficiency virus-seronegative control subjects. No differences between the 2 groups were seen in the frequencies of sexually transmitted diseases.

Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials

Two randomised controlled trials of sexually transmitted disease (STD) treatment for the prevention of HIV-1 Infection, in Mwanza, Tanzania, and Rakai, Uganda, unexpectedly produced contrasting results. A decrease in population HIV-1 incidence was associated with improved STD case management in Mwanza, but was not associated with STD mass treatment in Rakai. Some reductions in curable STDs were seen in both studies. These trials tested different interventions in different HIV-1 epidemic settings and used different evaluation methods; the divergent results may be complementary rather than contradictory. Possible explanations include: differences in stage of the HIV-1 epidemic, which can influence exposure to HIV-1 and the distribution of viral load in the infected population; potential differences in the prevalence of Incurable STDs (such as genital herpes); perhaps greater Importance of symptomatic than symptomless STDs for HIV-1 transmission; and possibly greater effectiveness of continuously available services than of intermittent mass treatment to control rapid STD reinfection. Implications of the trials for policy and future research agenda are discussed.

Identification of a human lactoferrin-binding protein in Gardnerella vaginalis

Previous studies have shown that Gardnerella vaginalis can utilize iron-loaded human lactoferrin as a sole source of iron. In this study, G. vaginalis cells were shown to bind digoxigenin (DIG)-labeled human lactoferrin in a dot blot assay. Using the DIG-labeled human lactoferrin, a 120-kDa human lactoferrin-binding protein was detected by Western blot analysis of G. vaginalis proteins. The lactoferrin-binding activity of this protein was found to be heat stable. Competition studies indicated that this binding activity was specific for human lactoferrin. Treatment of G. vaginalis cells with proteases suggested that this protein was surface exposed. An increase in lactoferrin binding by the 120-kDa protein was observed in G. vaginalis cells grown under iron-restrictive conditions, suggesting that this activity may be iron regulated.

Sexually transmitted diseases and the increased risk for HIV transmission: implications for cost-effectiveness analyses of sexually transmitted disease prevention interventions

We estimated the annual number and cost of new HIV infections in the United States attributable to other sexually transmitted diseases (STDs). We used a mathematical model of HIV transmission to estimate the probability that a given STD infection would facilitate HIV transmission from an HIV-infected person to his or her partner and to calculate the number of HIV infections due to these facilitative effects. In 1996, an estimated 5,052 new HIV cases were attributable to the four STDs considered here: chlamydia (3,249 cases), syphilis (1,002 cases), gonorrhea (430 cases), and genital herpes (371 cases). These new HIV cases account for approximately $985 million U.S. in direct HIV treatment costs. The model suggested that syphilis is far more likely than the other STDs (on a per-case basis) to facilitate HIV transmission. This analysis provides a framework for incorporating STD-attributable HIV treatment costs into cost-effectiveness analyses of STD prevention programs.

Sexually transmitted infections in European HIV-infected women: incidence in relation to time from infection. European Study on the Natural History of HIV Infection in Women

OBJECTIVES

To investigate the prevalence and incidence of sexually transmitted infections (STI) in HIV-infected women in relation to time from infection and sexual behaviour.

DESIGN

The European study on the natural history of HIV infection in women is a prospective cohort study of 487 HIV-infected women with a known interval of seroconversion from 12 European countries.

METHODS

Incidence was measured with person-time methods. Generalized estimating equations analysis was used to determine risk factors for STI.

RESULTS

At entry, 15% of the women were diagnosed with at least one acute STI (chlamydial infection, trichomoniasis or gonorrhoea), 10% with at least one other STI (genital warts or genital ulcerations) and 13% with vaginal candidiasis. Although frequently diagnosed during follow-up, the occurrence of acute STI and vaginal candidiasis decreased, whereas the occurrence of other STI increased with ongoing time from HIV infection. Furthermore, women with a history of prostitution [relative risk (RR), 2.00; 95% confidence interval (95% CI), 1.20-3.33] and women with irregular condom use (RR, 7.74; 95% CI, 3.52-17.0) were at higher risk for an acute STI.

CONCLUSIONS

Although STI diagnoses were frequent, the occurrence of acute STI declined with time from infection which might be explained by changed sexual behaviour over time. The occurrence of other STI increased with time from HIV infection, presumably due to reactivation as a result of immunosuppression.

Model-based evaluation of single-round mass treatment of sexually transmitted diseases for HIV control in a rural African population

OBJECTIVES

To compare the impact of single-round mass treatment of sexually transmitted diseases (STD), sustained syndromic treatment and their combination on the incidence of HIV in rural Africa.

METHODS

We studied the effects of STD interventions by stochastic simulation using the model STDSIM. Parameters were fitted using data from a trial of improved STD treatment services in Mwanza, Tanzania. Effectiveness was assessed by comparing the prevalences of gonorrhoea, chlamydia, syphilis and chancroid, and the incidence of HIV, in the general adult population in simulations with and without intervention.

RESULTS

Single-round mass treatment was projected to achieve an immediate, substantial reduction in STD prevalences, which would return to baseline levels over 5-10 years. The effect on syphilis was somewhat larger if participants cured of latent syphilis were not immediately susceptible to re-infection. At 80% coverage, the model projected a reduction in cumulative HIV incidence over 2 years of 36%. A similar impact was achieved if treatment of syphilis was excluded from the intervention or confined to those in the infectious stages. In comparison with sustained syndromic treatment, single-round mass treatment had a greater short-term impact on HIV (36 versus 30% over 2 years), but a smaller long-term impact (24 versus 62% over 10 years). Mass treatment combined with improved treatment services led to a rapid and sustained fall in HIV incidence (57% over 2 years; 70% over 10 years).

CONCLUSIONS

In populations in which STD control can reduce HIV incidence, mass treatment may, in the short run, have an impact comparable to sustained syndromic treatment. Mass treatment combined with sustained syndromic treatment may be particularly effective.

Induction of vaginal Lactobacillus phages by the cigarette smoke chemical benzo[a]pyrene diol epoxide

Because smoking increases a woman's risk of contracting bacterial vaginosis (BV), which is manifested by a reduction of vaginal lactobacilli and an overgrowth of anaerobic bacteria, chemicals contained in cigarette smoke were analyzed in vitro to determine their role in reducing lactobacilli. The result showed that trace amounts of benzo[a]pyrene diol epoxide (BPDE), which can be found in vaginal secretion of women who smoke, significantly increased phage induction in lactobacilli. This finding implies that smoking may reduce vaginal lactobacilli by promoting phage induction.

Treatment of sexually transmitted bacterial diseases in pregnant women

Testing for and treating sexually transmitted diseases (STDs) in pregnant women deserves special attention. Treatment possibilities are limited because of potential risks for the developing fetus, and because effects can differ in pregnant compared with non-pregnant women, re-infection may be missed because of the intrinsic delicacy of contact-tracing during pregnancy and because pregnant women are more reluctant to take the prescribed medication in its full dose, if at all. However, the devastating effects of some of these genital infections far outweigh any potential adverse effects of treatment. Although active syphilis has become a rarity in most Western countries, it is still prevalent in South America, Africa and South-East Asia. Benzathine benzylpenicillin (2.4 million units once or, safer, twice 7 days apart) is the treatment of choice, although patients with syphilis of longer standing require 3 weekly injections as well as extensive investigation into whether there has been any damage due to tertiary syphilis. Despite declining rates of gonorrhea, the relative rate of penicillinase-producing strains is increasing, especially in South-East Asia. The recommended treatment is intramuscular ceftriaxone (125 or 250 mg) or oral cefixime 400 mg. Despite good safety records after accidental use, fluoroquinolones are contraindicated during pregnancy. An alternative to a fluoroquinolone in pregnant women with combined gonorrhea and chlamydial infection is oral azithromycin 1 or 2 g. Azithromycin as a single 1 g dose is also preferable to a 7 day course of erythromycin 500 mg 4 times a day for patients with chlamydial infection. Eradication of Haemophilus ducreyi in patients with chancroid can also be achieved with these regimens or intramuscular ceftriaxone 250 mg. Trichomonas vaginalis, which is often seen as a co-infection, has been linked to an increased risk of preterm birth. Patients infected with this parasite should therefore received metronidazole 500 mg twice daily for 7 days as earlier fears of teratogenesis in humans have not been confirmed by recent data. Bacterial vaginosis is also associated with preterm delivery in certain risk groups, such as women with a history of preterm birth or of low maternal weight. Such an association is yet to be convincingly proven in other women. The current advice is to treat only women diagnosed with bacterial vaginosis who also present other risk factors for preterm delivery. The treatment of choice is oral metronidazole 1 g/day for 5 days. The possible reduction of preterm birth by vaginally applied metronidazole or clindamycin is still under investigation. In general, both test of cure and re-testing after several weeks are advisable in most pregnant patients with STDs, because partner notification and treatment are likely to be less efficient than outside pregnancy and the impact of inadequately treated or recurrent disease is greater because of the added risk to the fetus. Every diagnosis of an STD warrants a full screen for concomitant genital disease. Most ulcerative genital infections, as well as abnormal vaginal flora and bacterial vaginosis, increase the sexual transmission efficiency of HIV, necessitating even more stringent screening for and treating of STD during pregnancy.

Clinical management and prevention of sexually transmitted diseases: a review focusing on women

This review highlights some of the difficulties inherent in controlling sexually transmitted diseases (STDs) in developing countries--especially amongst women. Considerable efforts have been made to improve the syndromic approach to STD management but the poor performance of the algorithm for managing vaginal discharge limits the effectiveness of this strategy. The facilitating role of the human immunodeficiency virus (HIV) has been the main impetus to STD control rather than reduction of morbidity in women, especially pregnant women and their children. There are no easy solutions--but action on several fronts, with more attention to core groups, men and adolescents is indicated.

Bacterial Vaginosis

Bacterial vaginosis, the most prevalent cause of vaginal discharge in the United States, is characterized microbiologically by a shift in the vagina away from a lactobacillus-predominant flora and toward a predominantly anaerobic milieu. The cause of bacterial vaginosis is unknown, but the epidemiology of the syndrome suggests that it is sexually associated. Bacterial vaginosis has been associated with various complications, such as pelvic inflammatory disease, preterm birth, postoperative gynecologic infections, and abnormal Pap smears. Abnormal vaginal flora may also be a biologic risk factor for sexually transmitted diseases, including HIV infection.

Gynecologic conditions and bacterial vaginosis: implications for the non-pregnant patient

Bacterial vaginosis is characterized by a shift from the predominant lactobacillus vaginal flora to an overgrowth of anaerobic bacteria. Bacterial vaginosis is associated with an increased risk of gynecologic complications, including pelvic inflammatory disease, postoperative infection, cervicitis, human immunodeficiency virus (HIV), and possibly cervical intraepithelial neoplasia (CIN). The obstetrical risks associated with bacterial vaginosis include premature rupture of membranes, preterm labor and delivery, chorioamnionitis and postpartum endometritis. Despite the health risks associated with bacterial vaginosis and its high prevalence in women of childbearing age, bacterial vaginosis continues to be largely ignored by clinicians, particularly in asymptomatic women.

Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on efficacy of ambulatory oral therapy

OBJECTIVE

This study was undertaken to determine the effects of human immunodeficiency virus 1 infection on the clinical presentation, severity, causal organisms, and response to ambulatory therapy of pelvic inflammatory disease.

STUDY DESIGN

Women 18 to 40 years old with lower abdominal pain for <1 month were recruited. Participants underwent a standardized questionnaire, physical examination, screening for human immunodeficiency virus 1 and other sexually transmitted infections, and endometrial biopsy to detect plasma cell endometritis. Reevaluations were performed at 1 and 4 weeks to assess response to therapy.

RESULTS

Among 162 women with adequate endometrial biopsy specimens 63 (39%) had histologically confirmed endometritis. Endometritis was more frequent among women who were seropositive for human immunodeficiency virus 1 than among women who were seronegative (odds ratio, 3.0; 95% confidence interval, 1.5-5.9). Infections with either Neisseria gonorrhoeae or Chlamydia trachomatis, or both, were least common and bacterial vaginosis was most common among human immunodeficiency virus 1-infected women with CD4 T-lymphocyte counts <400 cells/microL (P <. 04, P <.03, respectively). After oral antibiotic therapy, similar proportions of both women who were seropositive and women who were seronegative for human immuno-deficiency virus 1 had a >/=75% reduction in clinical severity score (81% vs 86%).

CONCLUSION

Outpatient treatment of pelvic inflammatory disease was successful regardless of human immunodeficiency virus 1 serostatus.

Prevalence of lower genital tract infections among human immunodeficiency virus (HIV)-seropositive and high-risk HIV-seronegative women. HIV Epidemiology Research Study Group

This study was undertaken to assess whether the prevalence of lower genital tract infections among human immunodeficiency virus (HIV)-seropositive women was higher than among high-risk HIV-seronegative women at their baseline visit for the HIV Epidemiology Research Study. Results were available for 851 HIV-seropositive and 434 HIV-seronegative women. Human papilloma virus (HPV) infection was more prevalent among HIV-seropositive women (64% vs. 28%). Bacterial vaginosis was common (35% vs. 33%), followed by trichomoniasis (12% vs. 10%), syphilis (8% vs. 6%), Chlamydia trachomatis infection (4% vs. 5%), candidal vaginitis (3% vs. 2%), and Neisseria gonorrhoeae infection (0.8% vs. 0.3%). Alcohol use (odds ratio [OR], 1.8; 95% confidence interval [CI], 1. 3-2.4) and smoking (OR, 1.8; 95% CI, 1.3-2.5) were associated with bacterial vaginosis. Bacterial vaginosis (OR, 2.3; 95% CI, 1.5-3.4), trichomoniasis (OR, 2.3; 95% CI, 1.1-4.7), and syphilis (OR, 3.1; 95% CI, 1.3-7.4) were found to be more prevalent among black women. Our study showed no statistically significant difference in the prevalence of lower genital tract infections except for HPV between HIV-infected and demographically and behaviorally similar HIV-uninfected high-risk women.

Bacterial vaginosis is not associated with circumcision status of the current male partner

OBJECTIVE

Bacterial vaginosis (BV) is common in sexually active women, and in a large proportion the underlying aetiology is unknown. We evaluated partner circumcision status as a potential risk and hypothesised that women with uncircumcised partners were at increased risk for BV.

METHODS

Retrospective audit of a partner study (272 heterosexual couples) conducted in Baltimore between 1990 and 1992. BV defined by clinical criteria and circumcision status of males was determined by physical examination.

RESULTS

BV was diagnosed in 83 (30%) female partners; 75 (27%) males were uncircumcised. In males and females respectively, gonorrhoea was diagnosed in 20% and 16%, and chlamydia in 7% and 11%. In women with circumcised partners, 58/197 (29%) had BV compared with 25/75 (33%) with uncircumcised partners (p = 0.53).

CONCLUSION

Women with uncircumcised current partners are not at increased risk for BV.

Association of indicators of bacterial vaginosis with a female genital tract factor that induces expression of HIV-1

OBJECTIVE

The aim of this study was to determine the relationship of bacterial vaginosis and bacterial vaginosis-associated microorganisms with an HIV-inducing factor (HIF) found in cervicovaginal lavage.

DESIGN

A total of 26 cervicovaginal lavage specimens collected from 17 women were used in this study to determine if HIF was significantly associated with features consistent with bacterial vaginosis.

METHODS

Patients were evaluated for various clinical features including age, HIV status and stage, CD4 cell counts, clinical diagnosis of gynecological infections, vaginal pH, Gram stains of vaginal fluid, phase of menstruation, and presence of cervical dysplasia. Cervicovaginal lavage specimens were analyzed for the presence of HIF by U1 bioassay. The presence of Gardnerella vaginalis, and general Mycoplasmataceae, and specifically Mycoplasma hominis, Ureaplasma urealyticum, M. fermentans, M. genitalium in cervicovaginal lavage were determined by semiquantitative PCR.

RESULTS

Eleven cervicovaginal lavage samples from seven women were HIF-positive and 15 cervicovaginal lavage samples from 11 women were HIF-negative (patient No. 8 had two HIF-negative cervicovaginal lavage and one HIF-positive cervicovaginal lavage). The following parameters were significantly associated with HIF: abnormal vaginal fluid pH (>4.5) (P = 0.006), Gram stains indicative of bacterial vaginosis (P = 0.007), normal menstrual cycle (P = 0.0007) and PCR detection and relative quantity of M. hominis (P = 0.0003, P = 0.002).

CONCLUSIONS

This study indicates that HIF is closely associated with features of bacterial vaginosis.

Predictors of condom use among patients with sexually transmitted diseases in Uganda

BACKGROUND AND OBJECTIVE

Patients with sexually transmitted diseases (STDs) are at an increased risk of HIV infection and they must be targeted for increased condom use.

GOAL

To identify predictors of condom use among patients with STDs.

STUDY DESIGN

In a cross-sectional survey, an interview-administered questionnaire was administered to 138 patients at the STD clinic, Mulago, and the outpatients department, Mbarara Hospital, in Uganda. Data were collected on socio-demographic situations, STD symptoms, type of sexual partners, and use of condoms. Multivariate logistic regression models were used to identify independent predictors of condom use.

RESULTS

Of the 138 patients, 87 (66%) knew how to use condoms, 81 (59%) ever used a condom, 34 (25%) used a condom at least once in the previous 3 months, 20 (15%) used a condom during the last sexual intercourse, and 80 (58%) accepted a free supply of condoms. Reasons for not using condoms among the 57 who had never were: having a regular partner or spouse (28, 49%), partner does not approve (17, 30%), reduced sexual pleasure (5, 9%), and no answer (7, 12%). The independent predictors of condom use were: being a man, not having a regular partner, having had sex with a casual partner, being able to read English, having at least secondary education, and using electricity for lighting.

CONCLUSION

Providing health promotion messages in local languages may improve condom use in this population. There is a need for complementary HIV prevention strategies for women and for regular sexual partnerships.

Gynecologic Complications of Bacterial Vaginosis: Fact or Fiction?

Bacterial vaginosis is a complex alteration of vaginal flora causing mild symptoms in women characterized by a milky vaginal discharge associated with a fishy odor worsened after unprotected vaginal coitus. It is the most common cause of vaginitis. It is now clear that this seemingly harmless disorder causing nuisance symptoms is linked to a number of important adverse reproductive tract sequelae, including the obstetrical sequelae of preterm labor and delivery. Literature published over the past year continue to support the association of bacterial vaginosis with adverse gynecologic sequelae in women.

Is There a Protective Role for Vaginal Flora?

The notion of a protective vaginal flora is relatively new. Resident flora manifest colonization resistance to prevent or reduce the likelihood of exogenous microorganisms, viruses, bacteria, yeast, or parasites becoming established in the lower genital tract of women following sexual (HIV, Neisseria gonorrhoeae, Escherichia coli, Candida albicans, Trichomonas vaginalis) or nonsexual (uropathogenic E. coli) transmission. The concept of preserving or reestablishing protective flora has been hastened by several factors, including the potential widespread use of vaginal microbicides, the increased heterosexual spread of HIV, and the imminent availability of exogenous Lactobacillus species probiotic therapy.

Seroprevalence and incidence of genital ulcer infections in a rural Ugandan population

OBJECTIVES

To determine age-sex specific seroprevalence and incidence rates of Treponema pallidum, Haemophilus ducreyi, and HSV-2; to assess the association between HIV-1 status and incidence of these STIs; and HSV-2 serostatus with number of lifetime sexual partners.

METHODS

Antibodies against HIV-1, T pallidum, H ducreyi, and HSV-2 infections were tested using approximately 1000 paired (2 year interval) sera collected from a rural adult (15-54 years) population cohort in south west Uganda.

RESULTS

Overall HIV-1 prevalence was 4.9%. Prevalence for T pallidum was 12.9% among males and 12.6% among females. The corresponding rates for H ducreyi were 9.8% and 7.3% respectively. HSV-2 prevalence rates were considerably lower in males (36.0%) than in females (71.5%), p < 0.001. Incidence rates for T pallidum per 1000 person years of observation were 8.4 for males and 12.3 for females. The corresponding rates for H ducreyi were 24.6 and 20.0 and for HSV-2 were 73.2 and 122.9 per 1000 person years of observation, respectively. The RR of HSV-2 incidence was 3.69 in HIV seropositive cases versus HIV seronegative after adjusting for age and sex. The corresponding RR for H ducreyi was 3.50 among female HIV positive cases versus negatives with no effect seen in males. Association between HIV-1 prevalence and prevalence of other STIs was significant (Mantel-Haenszel test) for H ducreyi (p = 0.01) and for HSV-2 (p = 0.004) but not for T pallidum (p > 0.4). HSV-2 prevalence was associated with number of lifetime sexual partners (females, p = 0.003; males, p = 0.08).

CONCLUSIONS

The results have provided a reliable estimate of the magnitude of the STI problem and demonstrated an association between HIV-1 status and serology of other STIs in a general rural population in sub-Saharan Africa. The study has also highlighted a correlation between HSV-2 seropositivity and number of reported lifetime sexual partners.

The use of epidemiologic mass treatment and syndrome management for sexually transmitted disease control

BACKGROUND

Epidemiologic mass treatment and syndrome management are two sexually transmitted disease (STD) control strategies that are receiving increased attention internationally. The former is a population-based intervention, whereas the latter attempts to improve the quality and efficiency of clinic-based STD case management.

METHODS

The published literature on these subjects was reviewed.

RESULTS

Epidemiologic mass treatment refers to treatment of whole communities (mass treatment) or high-risk subgroups within communities (targeted presumptive treatment) based on high STD prevalence rates. Syndrome management overcomes many obstacles to provision of quality STD case management by basing treatment decisions on recognition of easily identifiable syndromes. Experience with application of these strategies is summarized, and their possible use as STD control measures in communities with similar conditions is discussed.

CONCLUSIONS

Epidemiologic mass treatment may be an effective approach to rapidly reduce STD transmission in high prevalence communities, especially when high-risk core groups are effectively reached. Once high prevalence rates are brought down, however, longer term strategies, including improved STD case management, are essential to maintain reduced rates.

Bacterial vaginosis associated with HIV infection in pregnant women from North Carolina

BACKGROUND

We investigated whether bacterial vaginosis is associated with HIV infection in pregnant women in North Carolina, U.S.A.

METHODS

At 24 to 29 weeks' gestation, we recruited 724 women receiving prenatal care to provide interview information and vaginal swabs for Gram's stain scoring of vaginal flora.

FINDINGS

As vaginal flora score increased, prevalence of HIV increased (trend p = .03). HIV prevalence was 0.8% (4 of 489 patients), 1.2% (1 of 84 patients), and 3.3% (5 of 151 patients) among women with normal, intermediate, and abnormal vaginal flora, respectively. All HIV-infected women were free from AIDS and were taking antiretroviral medication. Compared with women with normal vaginal flora, the relative risk for prevalence of HIV infection with intermediate flora was 1.5 (95% confidence interval [CI], 0.2, 12.9) and with abnormal flora was 4.0 (95% CI, 1.1, 14.9). The association between abnormal vaginal flora and HIV infection could not be explained by age, ethnicity, number of sexual partners in the past 6 months, sexually transmitted diseases (STDs), or douching during pregnancy.

INTERPRETATION

In a population with a relatively low HIV prevalence, vaginal flora abnormalities were associated with prevalent HIV infection. We cannot determine whether vaginal flora abnormalities increase women's susceptibility to HIV infection or become more common after infection. The increased prevalence of bacterial vaginosis among HIV-infected pregnant women increases risk for preterm delivery. Incidence studies are required to discern whether control of bacterial vaginosis might reduce HIV infectivity.

Lower genital tract infections among HIV-infected and high-risk uninfected women: findings of the Women's Interagency HIV Study (WIHS)

BACKGROUND AND OBJECTIVES

Few comparisons of factors associated with sexually transmitted diseases (STDs) and HIV are available for representative samples of American women.

GOAL OF THE STUDY

To compare factors associated with STDs in a large sample of women infected with HIV and women not infected with HIV.

STUDY DESIGN

A cross-sectional analysis of STDs in 2,058 women seropositive (HIV+) for HIV and 567 women seronegative (HIV-) for HIV.

RESULTS

HIV + women were more likely than HIV- women to report previous STDs, with the exceptions of chlamydia and bacterial vaginosis. Both HIV status and CD4 lymphocyte count were associated with evidence of genital ulcerations, warts, and vaginal candidiasis (p <0.001 for all). HIV- women were more apt to report recent vaginal intercourse (p <0.001), a factor that was independently associated with the occurrence of bacterial and protozoan infections. CD4 lymphocyte depletion was the factor most closely associated with the expression of chronic viral infections.

CONCLUSIONS

In this North American cohort, HIV+ women were more likely than HIV- women to report previous genital tract infections and symptoms. However, the HIV+ women reported less recent sexual activity and few gonococcal or chlamydial infections.

Increased interleukin-10 in the the endocervical secretions of women with non-ulcerative sexually transmitted diseases: a mechanism for enhanced HIV-1 transmission?

OBJECTIVE

Although non-ulcerative sexually transmitted diseases (STD) and bacterial vaginosis are implicated as cofactors in heterosexual HIV-1 transmission, the mechanisms have not been defined. Recent in vitro data suggest that interleukin (IL)-10 may increase susceptibility of macrophages to HIV-1 infection. Therefore, we performed this study to assess whether non-ulcerative STD are associated with detection of IL-10 in the female genital tract.

METHODS

Women with clinical pelvic inflammatory disease with or without cervicovaginal discharge were recruited from an STD clinic in Nairobi, Kenya. Endocervical and endometrial specimens were obtained for Neisseria gonorrhoeae and Chlamydia trachomatis DNA detection, Trichonomas vaginalis culture, and CD4 and CD8 T-cell enumeration. Bacterial vaginosis was diagnosed by Gram stain. IL-10 was detected in endocervical specimens using enzyme-linked immunosorbent assay. Blood was obtained for HIV-1 serology.

RESULTS

One hundred and seventy-two women were studied. N. gonorrhoeae, C. trachomatis, bacterial vaginosis, and T. vaginalis were detected in 38 (21%), 17 (9%), 71 (43%), and 22 (12%) women, respectively. Cervical IL-10 was detected more often in women with N. gonorrhoeae [adjusted odds ratio (AOR), 3.4; 95% confidence interval (CI), 1.4-8.4], C. trachomatis (AOR, 4.4; 95% CI, 1.2-15.6), and bacterial vaginosis (AOR, 3.1; 95% CI, 1.4-6.9) than in women without these infections.

CONCLUSIONS

The association of non-ulcerative STD and bacterial vaginosis with increased frequency of IL-10 detection in endocervical secretions suggests a potential mechanism through which these infections may alter susceptibility to HIV-1 infection in women.

Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomised community trial. Rakai Project Study Group

BACKGROUND

The study tested the hypothesis that community-level control of sexually transmitted disease (STD) would result in lower incidence of HIV-1 infection in comparison with control communities.

METHODS

This randomised, controlled, single-masked, community-based trial of intensive STD control, via home-based mass antibiotic treatment, took place in Rakai District, Uganda. Ten community clusters were randomly assigned to intervention or control groups. All consenting residents aged 15-59 years were enrolled; visited in the home every 10 months; interviewed; asked to provide biological samples for assessment of HIV-1 infection and STDs; and were provided with mass treatment (azithromycin, ciprofloxacin, metronidazole in the intervention group, vitamins/anthelmintic drug in the control). Intention-to-treat analyses used multivariate, paired, cluster-adjusted rate ratios.

FINDINGS

The baseline prevalence of HIV-1 infection was 15.9%. 6602 HIV-1-negative individuals were enrolled in the intervention group and 6124 in the control group. 75.0% of intervention-group and 72.6% of control-group participants provided at least one follow-up sample for HIV-1 testing. At enrolment, the two treatment groups were similar in STD prevalence rates. At 20-month follow-up, the prevalences of syphilis (352/6238 [5.6%]) vs 359/5284 [6.8%]; rate ratio 0.80 [95% CI 0.71-0.89]) and trichomoniasis (182/1968 [9.3%] vs 261/1815 [14.4%]; rate ratio 0.59 [0.38-0.91]) were significantly lower in the intervention group than in the control group. The incidence of HIV-1 infection was 1.5 per 100 person-years in both groups (rate ratio 0.97 [0.81-1.16]). In pregnant women, the follow-up prevalences of trichomoniasis, bacterial vaginosis, gonorrhoea, and chlamydia infection were significantly lower in the intervention group than in the control group. No effect of the intervention on incidence of HIV-1 infection was observed in pregnant women or in stratified analyses.

INTERPRETATION

We observed no effect of the STD intervention on the incidence of HIV-1 infection. In the Rakai population, a substantial proportion of HIV-1 acquisition appears to occur independently of treatable STD cofactors.

Bacterial vaginosis: sequelae and management

The prevalence and complications of bacterial vaginosis are population dependent. In pregnancy, bacterial vaginosis is associated with late miscarriages and infection driven pre-term delivery. Regardless of the aetiology of pre-term delivery, surviving infants are at increased risk of subsequent neurodevelopmental handicap. Intervention studies in bacterial vaginosis positive pregnant women at high risk of pre-term delivery demonstrate the benefits of antibiotic treatment. Current evidence suggests that bacterial vaginosis may increase the efficiency of heterosexual HIV transmission. Metronidazole remains the mainstay of treatment of bacterial vaginosis. No treatment prevents relapse, which occurs in 20-30% of cases within 1 month. New approaches that are based on a better understanding of the pathophysiology of bacterial vaginosis are required to improve the clinical management of recurrent bacterial vaginosis.

Race/ethnicity, vaginal flora patterns, and pH during pregnancy

OBJECTIVES

To investigate the relationship between bacterial vaginosis during pregnancy and black race/ethnicity.

STUDY DESIGN

Gram staining was used to evaluate vaginal flora in 842 women at 24 to 29 weeks' gestation.

RESULTS

Overall, 22.3% of blacks and 8.5% of whites had bacterial vaginosis. Vaginal pH and flora differed significantly by race/ethnicity; blacks were more likely to have pH > or = 4.5, no lactobacilli, small gram-variable and -negative rods, and Mobiluncus compared with whites (odds ratios 1.6, 1.5, 1.4, and 10.6, respectively). Quantity of morphotypes also differed, especially for Mobiluncus. Among women with Mobiluncus present (12.0% of blacks and 1.3% of whites), 73.3% of blacks compared with 40.0% of whites had the highest level. Adjustment for sociodemographics, sexual activity, sexually transmitted diseases, health behavior, and sexual hygiene did not explain these differences.

CONCLUSION

We observed race/ethnicity differences in vaginal flora ecology. These differences may ultimately play a role in the larger proportion of preterm deliveries among black women compared with white women.

From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection

OBJECTIVES

To review the scientific data on the role of sexually transmitted diseases (STDs) in sexual transmission of HIV infection and discuss the implications of these findings for HIV and STD prevention policy and practice.

METHODS

Articles were selected from a review of Medline, accessed with the OVID search engine. The search covered articles from January 1987 to September 1998 and yielded 2101 articles. Methods used to uncover articles which might have been missed included searching for related articles by author, and combing literature reviews. In addition, all abstracts under the category "sexually transmitted diseases" from the XI and XII International Conferences on AIDS (Vancouver 1996 and Geneva 1998) and other relevant scientific meetings were reviewed. Efforts were made to locate journal articles which resulted from the research reported in the identified abstracts. All original journal articles and abstracts which met one of the following criteria were included: (1) studies of the biological plausibility or mechanism of facilitation of HIV infectiousness or susceptibility by STDs, (2) prospective cohort studies (longitudinal or nested case-control) which estimate the risk of HIV infection associated with specific STDs or STD syndromes, or (3) intervention studies which quantitate the effect which STD treatment can have on HIV incidence.

RESULTS

Strong evidence indicates that both ulcerative and non-ulcerative STDs promote HIV transmission by augmenting HIV infectiousness and HIV susceptibility via a variety of biological mechanisms. These effects are reflected in the risk estimates found in numerous prospective studies from four continents which range from 2.0 to 23.5, with most clustering between 2 and 5. The relative importance of ulcerative and non-ulcerative STDs appears to be complex. Owing to the greater frequency of non-ulcerative STDs in many populations, these infections may be responsible for more HIV transmission than genital ulcers. However, the limited reciprocal impact of HIV infection on non-ulcerative STDs and the evidence that non-ulcerative STDs may increase risk primarily for the receptive partner (rather than bidirectionally) may modulate the impact of these diseases. The results of two community level randomised, controlled intervention trials conducted in Africa suggest that timely provision of STD services can substantially reduce HIV incidence, but raise additional questions about the optimal way to target and implement these services to achieve the greatest effect on HIV transmission.

CONCLUSIONS

Available data leave little doubt that other STDs facilitate HIV transmission through direct, biological mechanisms and that early STD treatment should be part of a high quality, comprehensive HIV prevention strategy. Policy makers, HIV prevention programme managers, and providers should focus initial implementation efforts on three key areas: (i) improving access to and quality of STD clinical services; (ii) promoting early and effective STD related healthcare behaviours; and (iii) establishing surveillance systems to monitor STD and HIV trends and their interrelations.

HIV infection and disturbances of vaginal flora during pregnancy

Disturbances of vaginal flora are common among women of reproductive age. In areas of sub-Saharan Africa where the prevalence of HIV is high, the frequency of bacterial vaginosis (BV) is also high. In this study, we assessed the association of BV and other disturbances of vaginal flora with prevalent HIV infection in two cross-sectional studies among pregnant women in urban Malawi. The prevalence of HIV-1 was 23% in 1990 and 30% in 1993. Overall, 30% of the women had BV, 59% had mild or moderate disturbance of vaginal flora, and only 11% had normal vaginal flora. Increasing prevalence of HIV was significantly associated with increasing severity of disturbance of vaginal flora (p < .00001, chi2 trend test). This trend of increased prevalence persisted after controlling for concurrent sexually transmitted diseases (STDs), sexual activity, and socioeconomic factors. After multivariate adjustment for potential confounders, the odds ratio for the association of BV with prevalent HIV infection was 3.0 (95% confidence interval [CI], 2.4-3.8), that of moderate vaginal disturbance with HIV infection was 2.2 (95% CI, 1.7-2.8), and that of mild vaginal disturbance with HIV infection was 1.6 (95% CI, 1.3-2.1). Among women with BV, HIV infection was higher among younger women than older, implying more recent infection. Although these studies were cross-sectional, our data suggest that BV could be associated with increased susceptibility to HIV infection.

Current approach to STD management in women

HIV infection was recognized as a new sexually transmitted disease (STD) at the beginning of the last decade. The knowledge of risk factors for sexual transmission of HIV changed the focus on STD to a broader perspective for prevention and control of HIV infection, and consequently of STD. Barriers to STD control include cultural aspects, difficulties in changing sexual behavior, asymptomatic disease in women and expensive and inaccessible tests for diagnosis. The classical clinical approach based on etiologic treatment has never been achieved by developing countries. The international community has been searching for new approaches. Syndromic management and mass treatment are strategies recently found as useful. Nevertheless the best approach to endocervicitis by Neisseria gonorrhoeae and Chlamydia trachomatis remain problematic. Then, the current approach to STD management must include: prompt attention to every patient seeking care for STD; early diagnosis and treatment; delivery of short term treatment at the clinic; education on STD/HIV; screening for other STDs with pre- and post-test counseling; counseling on risk reduction; provision of condoms; integration of STD services with family planning, prenatal and gynecological services.

Use of PCR to measure HIV viral changes in drug-resistant genes in genital fluids

Our group has been studying HIV in genital fluids for several years. Our first findings demonstrated that both RNA PCR and proviral DNA PCR could be utilized to quantify virus within seminal interstitial fluid and non-spermatozoa mononuclear cells, respectively. It became clear that these techniques were more sensitive than viral culture and we also reported that both disease progression and treatment influenced sperm viral concentrations generally parallel to virus concentrations in blood. A more recent study from our group has demonstrated that mutations seen in the virus in the blood are seen in the seminal plasma viral as well as in the proviral forms within non-spermatozoa cells. We have also studied female patients for 2-month periods looking at RNA in plasma and cervical secretions, as well as proviral DNA in cervical and vaginal samples by polymerase chain reaction (PCR) amplification techniques. The HIV RNA levels again appears to be the most sensitive and well-related to systemic viral load. Thus, genital secretion of cell-free virus and cells containing proviral DNA in both sexes parallels systemic virus levels, is a site for measurement of transmission of drug-resistant virus and should be monitored in therapy as well as in pathogenesis studies.

Asymptomatic non-ulcerative genital tract infections in a rural Ugandan population

OBJECTIVE

To document the prevalence of asymptomatic non-ulcerative genital tract infections (GTI) in a rural African cohort.

METHODS

The study population consisted of all adults aged 15-59 residing in 56 rural communities of Rakai District, southwest Uganda, enrolled in the Rakai STD Control for AIDS Prevention Study. Participants were interviewed about the occurrence of vaginal or urethral discharge and frequent or painful urination in the previous 6 months. Respondents were asked to provide blood and a first catch urine sample. Serum was tested for HIV-1. Urine was tested with ligase chain reaction (LCR) for N gonorrhoeae and C trachomatis. Women provided two self administered vaginal swabs; one for T vaginalis culture and the other for a Gram stained slide for bacterial vaginosis (BV) diagnosis.

RESULTS

A total of 12,827 men and women were enrolled. Among 5140 men providing specimens, 0.9% had gonorrhoea and 2.1% had chlamydia. Among 6356 women, 1.5% had gonorrhoea, 2.4% had chlamydia, 23.8% were infected with trichomonas and 50.9% had BV.53% of men and 66% of women with gonorrhoea did not report genital discharge or dysuria at anytime within the previous 6 months. 92% of men and 76% of women with chlamydia and over 80% of women with trichomonas or BV were asymptomatic. The sensitivities of dysuria or urethral discharge for detection of infection with either gonorrhoea or chlamydia among men were only 21.4% and 9.8% respectively; similarly, among women the sensitivity of dysuria was 21.0% while that of vaginal discharge was 11.6%. For trichomonas or BV the sensitivity of dysuria was 11.7% and that of vaginal discharge was 10.5%.

CONCLUSION

The prevalence of non-ulcerative GTIs is very high in this rural African population and the majority are asymptomatic. Reliance on reported symptoms alone would have missed 80% of men and 72% of women with either gonorrhoea or chlamydia, and over 80% of women with trichomonas or BV. To achieve STD control in this and similar populations public health programmes must target asymptomatic infections.

Acquisition of iron by Gardnerella vaginalis

Six Gardnerella vaginalis strains were examined for the ability to utilize various iron-containing compounds as iron sources. In a plate bioassay, all six strains acquired iron from ferrous chloride, ferric chloride, ferrous sulfate, ferric ammonium citrate, ferrous ammonium sulfate, bovine and equine hemin, bovine catalase, and equine, bovine, rabbit, and human hemoglobin. All six strains also acquired iron from human lactoferrin, but not from human transferrin, as determined by a liquid broth growth assay. Siderophore production was detected in eight G. vaginalis strains by the chrome azurol S universal chemical assay. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the cytoplasmic membrane proteins isolated from G. vaginalis 594 grown under iron-replete and iron-restricted conditions revealed several iron-regulated proteins ranging in molecular mass from 33 to 94 kDa. These results indicate that G. vaginalis may acquire iron from iron salts and host iron compounds.