Cervical ectopy in adolescent girls with and without human immunodeficiency virus infection

Understanding sexual behaviors of youth from the lens of caregivers, teachers, local leaders and youth in Homabay County, Kenya

In Kenya similar to other countries in Eastern and Southern Africa There is a disproportionately high burden of the global HIV incidence among youth ages 15-24 years, and where adolescent girls and young women account for up to a third of all incident HIV infections and more than double the burden of HIV compared to their male peers. Previous work has shown early sexual debut as entry point into risks to sexual and reproductive health among young people including STI/HIV acquisition. This was a formative assessment of the local context of three sexual risk behaviors among youth ages of 15-24 years: early sexual debut, multiple sexual partnerships, and age-mixing /intergenerational sex for purposes of informing comprehensive combination HIV intervention program design. We conducted a cross-sectional formative qualitative study in four sub-counties within Homabay county a high HIV prevalence region of Kenya. Participants were recruited through youth groups, schools, government offices and, community gatekeepers using approved fliers, referred to a designated venue for focus group discussion (FGD). After oral informed consent, twelve FGDs of 8-10 participants were carried out. Transcripts and field notes were uploaded to Atlas.ti qualitative data analysis and research software (version 8.0, 2017, ATLAS.ti GmbH). Open coding followed by grouping, categorization of code groups, and thematic abstraction was used to draw meaning for the data. A total of 111 youth participated in the FGD, 65 males and 46 females. The main findings were that youth engaged in early sex for fear of being labeled 'odd' by their peers, belief (among both male and female) that 'practice makes perfect', curiosity about sex, media influence, need to prove if one can father a child (among male), the notion that sex equals love with some of the youth using this excuse to coerce their partners into premature sex, and the belief that sex is a human right and parents/guardians should not intervene. Male youth experienced more peer-pressure to have sex earlier. Female youths cited many reasons to delay coitarche that included fear of pregnancy, burden of taking care of a baby, and religious doctrines. Having multiple sexual partners and intergenerational sexual relationships were common among the youth driven by perceived financial gain and increased sexual prowess. HIV prevention strategies need to address gender vulnerabilities, as well as promoting a protective environment, hence application of combination prevention methods is a viable solution to the HIV pandemic.Trial registration number: The study was approved by the KNH/UoN Ethics review committee (KNH/UoN ERC-P73/03/2011) and New York University (NYU Reg no.-00000310).

HIV Pathogenesis in the Human Female Reproductive Tract

PURPOSE OF REVIEW

Women remain disproportionately affected by the HIV/AIDS pandemic. The primary mechanism for HIV acquisition in women is sexual transmission, yet the immunobiological factors that contribute to HIV susceptibility remain poorly characterized. Here, we review current knowledge on HIV pathogenesis in women, focusing on infection and immune responses in the female reproductive tract (FRT).

RECENT FINDINGS

We describe recent findings on innate immune protection and HIV target cell distribution in the FRT. We also review multiple factors that modify susceptibility to infection, including sex hormones, microbiome, trauma, and how HIV risk changes during women's life cycle. Finally, we review current strategies for HIV prevention and identify barriers for research in HIV infection and pathogenesis in women. A complex network of interrelated biological and sociocultural factors contributes to HIV risk in women and impairs prevention and cure strategies. Understanding how HIV establishes infection in the FRT can provide clues to develop novel interventions to prevent HIV acquisition in women.

Association of Sexually Transmitted Diseases With Cervical Ectopy: A Systematic Review

OBJECTIVE

The aim of this study was to review the available literature to explore evidence indicating an association between cervical ectopy and sexually transmitted diseases, which could help in the decision to treat or not to treat this condition.

METHODS

A review of the literature was conducted using the PubMed, EMBASE and clinicaltrials.gov databases on ectopy of the cervix using the terms "ectopy OR ectropium AND cervix" filtered only by language, without limit of date. A total of 71 studies were found in the initial selection, of which 56 were deleted by title, abstract, or full text. The remaining 15 articles were analyzed in this study.

RESULTS

Cervical ectopy showed a positive association with human papillomavirus, human immunodeficiency virus, bacterial vaginosis, cervical epithelial atypia, postcoital bleeding, and desquamative inflammatory vaginitis. High-quality studies reported no association between ectopy and chlamydia infection. It was also not associated with gonococcal infection and herpes simplex.

CONCLUSIONS

Cervical ectopy shows a probable association with increased acquisition of some sexually transmitted diseases. Additional studies are required to confirm the possible beneficial effects of treatment and to evaluate the possible complications of these treatments.

High prevalence of sexually transmitted infections among women screened for a contraceptive intravaginal ring study, Kisumu, Kenya, 2014

We assessed prevalence and correlates of bacterial vaginosis (BV) and sexually transmitted infections (STIs) including herpes simplex virus type 2 (HSV-2), gonorrhoea (GC), syphilis (SYP), Chlamydia (CT) and HIV among Kenyan women aged 18–34 years who were screened for a contraceptive intravaginal ring study. Women provided demographic, behavioural and medical information, and underwent medical evaluation, including a pelvic exam. We computed crude and adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using log-binomial regression. Of 463 women screened, 457 provided laboratory specimens and were included in the analysis. The median age was 25 years, interquartile range (21–28), and 68.5% had completed primary or lower education. Overall, 72.2% tested positive for any STI or BV. Point prevalence was 55.6, 38.5, 3.9, 2.0, 4.6, and 14.7% for HSV-2, BV, GC, SYP, CT, and HIV, respectively. Co-infection with HSV-2, BV, and HIV occurred in 28 (6.1%) participants. Having ≥1 STI/BV was associated with younger age at first sex (≤13 versus 17–19 years, aPR=1.27, 95% CI 1.07–1.51), history of exchange sex (aPR = 2.05, 95% CI 1.07–3.92), sexual intercourse in the past seven days (aPR = 1.17, 95% CI 1.01–1.36), and older age (30–34 versus 18–24 years, aPR = 1.26, 95% CI 1.06–1.48). STI/BV diagnosis was less likely for women reporting one lifetime sexual partner compared to women with ≥4 lifetime sexual partners (aPR = 0.70, 95% CI 0.54–0.92). Combination prevention approaches (biomedical, behavioural, social, and structural) tailored to women with diverse risk profiles may help mitigate STI/BV prevalence in this setting.

Immune biomarkers and anti-HIV activity in the reproductive tract of sexually active and sexually inactive adolescent girls

PROBLEM

Adolescent girls are disproportionately affected by the HIV/AIDS pandemic, accounting for 22% of all new HIV infections globally. Yet little is known regarding the immune microenvironment of the adolescent female reproductive tract, especially regarding differences among sexually active and inactive girls, a critical parameter to evaluate HIV susceptibility associated with young age and sexual debut.

METHODS

Cervico-vaginal lavage (CVL) was collected from sexually active (10) and inactive (8) girls aged 11-19 years and analyzed by ELISA for inflammation-associated biomarkers IL-6, IL-8, TNF-α, MIP-3α, IL-1α, IL-1β, matrix metalloproteinases (MMP) 1, 2, 7, 8, and 9, as well as anti-HIV mediators, Elafin, SLPI, human beta-defensin 2, and tissue inhibitor of matrix metalloproteinases (TIMP) 1 and 2. Cervical ectopy was analyzed using Volocity. Anti-HIV activity was determined by TZM-bl assay. Statistical analyses were performed using GraphPad Prism and R.

RESULTS

Sexually inactive girls had significantly higher levels of TNF-α (P = .029) in CVL compared to sexually active girls. In contrast, sexually active girls showed a trend toward higher levels of IL-1α (P = .051) compared to the sexually inactive girls. Heat-map correlations between cervical ectopy and immune biomarkers were also distinct between the 2 populations with significant positive associations between % ectopy and inflammation-associated biomarkers IL-6, IL-1β, IL-8, MIP-3α, MMP-8, and MMP-9 observed in the sexually inactive but not sexually active group.

CONCLUSION

Higher pro-inflammatory biomarker TNF-α, as well as a distinct inflammation-associated immune clustering in sexually inactive girls, can potentially increase risk for infections including HIV upon sexual debut. Future studies with larger sample sizes are needed to characterize the immune parameters associated with sexual activity.

Patterns of prevalent HPV and STI co-infections and associated factors among HIV-negative young Western Cape, South African women: the EVRI trial

OBJECTIVE

To estimate the prevalence and describe the patterns of concurrent human papillomavirus (HPV) and STIs and associated factors among HIV-negative young Western Cape, South African women participating in the Efficacy of HPV Vaccine to Reduce HIV Infection (EVRI) trial.

METHODS

HIV-negative women aged 16-24 years old were enrolled in the EVRI trial (NCT01489527) and randomised to receive the licensed four-valent HPV vaccine or placebo. At study entry, participants were clinically evaluated for five STIs: herpes simplex virus type 2 (HSV-2), chlamydia, gonorrhoea, syphilis and disease-causing HPV genotypes (6/11/16/18/31/33/35/39/45/51/52/56/58/59/68). Demographic and sexual history characteristics were compared among women with STI co-infections, single infection and no infection using Pearson χ² and Mann-Whitney tests. ORs were calculated to evaluate factors associated with STI co-infection prevalence.

RESULTS

Among 388 young women, STI co-infection prevalence was high: 47% had ≥2 concurrent STIs, 36% had a single STI and 17% had none of the five evaluated STIs. HPV/HSV-2 (26%) was the most prevalent co-infection detected followed by HPV/HSV-2/Chlamydia trachomatis (CT) (17%) and HPV/CT (15%). Co-infection prevalence was independently associated with alcohol use (adjusted OR=2.01, 95% CI 1.00 to 4.06) and having a sexual partner with an STI (adjusted OR=6.96, 95% CI 1.53 to 30.08).

CONCLUSIONS

Among high-risk young women from underserved communities such as in Southern Africa, a multicomponent prevention strategy that integrates medical and behavioural interventions targeting both men and women is essential to prevent acquisition of concurrent STI infections and consequent disease.

TRIAL REGISTRATION NUMBER

NCT01489527; Post-results.

Cervical ectopy: associations with sexually transmitted infections and HIV. A cross-sectional study of high school students in rural South Africa

OBJECTIVES

It has been hypothesised that ectopy may be associated with increased susceptibility to sexually transmitted infections (STIs). In this cross-sectional study, we wanted to explore the association between STIs (including HIV) and cervical ectopy.

METHODS

We included 700 sexually active young women attending randomly selected high schools in a rural district in KwaZulu-Natal, South Africa. The district is endemic of HIV and has a high prevalence of STIs. We did computer-assisted measurements of the ectocervical area covered by columnar epithelium (ectopy) in colposcopic images and STI analyses on cervicovaginal lavage and serum samples. All participating women answered a questionnaire about sexual behaviour and use of contraceptives.

RESULTS

The mean age was 19.1 years. Ectopy was found in 27.2%, HIV in 27.8%, chlamydia in 25.3% and gonorrhoea in 15.6%. We found that age, parity, chlamydia and gonorrhoea, years since menarche, years since sexual debut and number of sexual partners were associated with ectopy. In multivariate analysis with chlamydia infection as the dependent variable, women with ectopy had increased odds of having chlamydia infection (adjusted OR 1.78, p=0.033). In women under 19 years of age, we found twofold higher odds of being HIV-positive for those with ectopy (OR 2.19, p=0.014).

CONCLUSIONS

In conclusion, cervical ectopy is associated with Chlamydia trachomatis infection and HIV in the youngest women.

Uterine cervical ectopy during reproductive age: cytological and microbiological findings

Cervical ectopy is common in adolescents, pregnant women, and those taking high doses of estrogen-containing contraceptives. The majority of cases have spontaneous reversion, but some cases can be persistent. Studies suggested that the adequacy of a Pap smear could be affected and there is an increased risk cervical infections. This study is a cross-sectional study conducted from December 2009 to February 2011 with 457 women with cervical ectopy and 736 without ectopy. Cervical samples were collected in vials for analysis by ThinPrep cytology (Hologic, Marlborough, MA). The Mann-Whitney test and Fisher's exact test (95% CI) were applied. The study was approved by the ethics committee of the Federal University of Ceará. The mean ages of the study group and control group were 28.7 (±14.8) and 33.6 (±7.5) years old, respectively (P < 0.0001). Negative diagnosis for malignancy and intraepithelial lesion was present in 399 (87%) cases and 705 (96%) in the study and control groups, respectively (P < 0.0001). Shift in the flora suggestive of bacterial vaginosis (BV) was observed more frequently in the study group: 74 (16.2%) than in the control group: 86(11.7%) (P = 0.017). The differences among the other morphotypes showed no significance. The smears were atypical in 12.7% (58/457) of the patients from the study group and in 4.2% (31/736) in the control group (P < 0.001; RR = 3 [2.033-4.712]). The association between ectopy and inflammatory cytology, the presence of the shift in the flora suggestive of BV and cytological atypia is evident.

Sperm exposure during menses is a risk factor for developing antisperm antibody (ASA) in female

PURPOSE

Intercourse during menses is a sexual behavior practiced by 3-30 % of sexually active women. Defense responses of mucosal immunity in the female genital tract regulated by sex hormones would be impaired during menses. The present study seeks to clarify whether unprotected sexual activity during menses will increase the risk for antisperm antibody (ASA) production in female.

METHODS

In this prospective study, 27 women who had a usual practice of vaginal intercourse during menses admitted in the First Affiliated Hospital of Jinan University with infertility were included, while 30 age-matched infertile women without this practice were set as controls. Indirect immunobead test (I-IBT) performed according to the World Health Organization (WHO) manual was used to measure the ASA levels.

RESULTS

No case was revealed to develop significant ASA level. 6 of 27 women (22.2 %) in the case group and 1 of 30 women (3.3 %) in the control group were detected to be ASA subpositive, and a significant difference was found in the subpositive incidence between these two groups (P < 0.05). Among these 6 subpositive cases, 3 became pregnant in the subsequent 2-year follow-up after condom therapy for 6 months.

CONCLUSIONS

Sperm exposure during menses is a risk factor for ASA production in female. Although a precisely causal linkage between ASA and infertility in these women cannot be drawn from the present data, the potential disadvantages of sexual activity during menses should still be given importance.

Intrauterine devices and pelvic inflammatory disease among adolescents

Adolescents may be ideal candidates for intrauterine device (IUD) use, given high rates of unintended pregnancy and less successful use of short-acting contraceptive methods. Concerns about elevated risks of pelvic inflammatory disease in adolescents, with the consequences of infertility, ectopic pregnancy, and pelvic pain, prevent many clinicians from inserting IUDs in adolescents. The body of evidence examining risks of pelvic infection related to IUD use specifically in adolescents is limited, but is reassuring that the absolute risk of pelvic infection is small and that the benefits of IUD use likely outweigh the risks.

Management of abnormal cervical cytology screening in adolescent and young women in a canadian colposcopy centre: a descriptive analysis

OBJECTIVE

To describe and analyze the management of young women referred for colposcopy at a Canadian comprehensive cancer centre for evaluation of atypical squamous intraepithelial lesion of unknown significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL).

METHODS

We conducted a retrospective descriptive study by searching the eCancerCare Colposcopy Database at our centre for 15- to 29-year-old females with referral cytology of ASC-US and LSIL who were seen between January 2000 and January 2009. Women in three age cohorts (15 to 19 years, 20 to 24 years, and 25 to 29 years) were reviewed for risk factors and relevant medical history, cytology and histology results, treatment, and follow-up visits.

RESULTS

A total of 407 women met the entry criteria, with 36 women in the group aged 15 to 19, 173 in the group aged 20 to 24, and 198 in the group aged 25 to 29. Ten excisional procedures were performed among the 36 participants in the group aged 15 to 19, with normal histology found in two (20%), low-grade cervical intraepithelial neoplasia (CIN) in four (40%), and high-grade CIN in four (40%). An excisional procedure was performed in 52 of 173 participants in the group aged 20 to 24, with normal histology in 15%, low-grade CIN in 37%, and high-grade CIN in 48%. Among the group aged 25 to 29, 74 of 198 participants had an excisional procedure, with normal histology in 12%, low-grade CIN in 27%, high-grade CIN in 59%, and microinvasive squamous cell carcinoma in one woman (1%).

CONCLUSION

Many women under the age of 25 who were referred with low-grade abnormal cervical cytology underwent treatment(s) and many did not have significant pathology. One case of microinvasive cervical cancer was identified in a patient in the group aged 25 to 29 over the nine years of our study. Our results support the safety of developing a more conservative and coordinated approach to cervical cancer screening in adolescent and young women in Canada.

Assessing the relationship between cervical ectopy and HIV susceptibility: implications for HIV prevention in women

Cervical ectopy, which occurs when the columnar epithelium of the endocervical canal extends outwards into the ectocervix, has been suggested to increase the susceptibility to HIV infection in at-risk women. This study summarizes observational studies, primarily conducted in sub-Saharan Africa, that have assessed a possible causative association between cervical ectopy and HIV acquisition and also examines the biological plausibility as well as other cofactors that may mediate this association. Only about half of the studies reviewed found cervical ectopy to be a significant risk factor for HIV acquisition. The reasons for these divergent results still remain to be fully elucidated. Understanding biological factors that affect HIV susceptibility provide opportunities to identify prevention strategies to reduce the risk of HIV acquisition.

Cervical ectopy and the acquisition of human papillomavirus in adolescents and young women

OBJECTIVE

Higher rates of human papillomavirus (HPV) in adolescents and younger women have been attributed to their greater extent of "cervical ectopy," defined as columnar and metaplastic epithelia on the ectocervix. Our objective was to estimate associations between ectopy and incident HPV in healthy adolescents and young women.

METHODS

Enrolled between October 2000 and October 2002, this prospective cohort included women aged 13-21 years who were sexually active, without previous cervical intraepithelial neoplasia, cervical procedures, or immunosuppression, with menarche within 6 years before enrollment, and negative for HPV DNA at baseline. Every 4 months, extent of ectopy was quantitatively measured using colpophotography and computerized planimetry. Cox proportional hazards models examined associations between ectopy and incident HPV, defined as the first positive HPV result during follow-up.

RESULTS

The 138 women attended 509 total visits. At baseline, mean age was 16.7 years and mean extent of ectopy was 25% of the total cervical face. Incident HPV of any type was detected in 42 (30%) women and was not significantly associated with baseline ectopy (hazard ratio 1.09, 95% confidence interval 0.96-1.25; P=.20; ectopy in units of 10%), or with ectopy measured 4 months before HPV detection (hazard ratio 1.09, confidence interval 0.94-1.26; P=.25). Our sample size had 80% power to detect a hazard ratio of 1.9 (with two-tailed α=0.05). Results were similarly insignificant for HPV subgroupings of incident high-risk, low-risk, α9, and α3/α15 types, and when adjusted for new sexual partners.

CONCLUSION

Extent of cervical ectopy was not associated with HPV acquisition in healthy adolescents and young women. Biological vulnerabilities may lie in immune function or other characteristics of the cervical epithelium.

LEVEL OF EVIDENCE

II.

Active squamous metaplasia of the cervical epithelium is associated with subsequent acquisition of human papillomavirus 16 infection among healthy young women

BACKGROUND

Vulnerability of younger women to human papillomavirus 16 (HPV16) infection has been attributed to the predominance of ectocervical columnar epithelia in this age group. However, squamous metaplastic tissue may be more influential. We examined the extent of ectopy and metaplastic activity as risks for HPV16 acquisition in a prospective cohort.

METHODS

Participants were HPV16 negative at the first two visits. Follow-up occurred every 4 months. Ectopy was quantitatively measured on colpophotographs. We calculated metaplastic rate as the difference in ectopy between visits. Cox proportional hazards models were constructed, adjusting for several covariates.

RESULTS

Analyses included 198 women (mean baseline age 17 years) for 1734 visits. Mean follow-up was 4.4 years. Incident HPV16 was detected in 36 (18%) women. Metaplastic rate between the two visits before HPV16 detection was significantly associated with incident infection (hazard ratio [HR], 1.17; confidence interval [CI], 1.02-1.33; P = .02). However, ectopy was not significant, whether measured before or concurrent to HPV16 detection (HR range, 0.99-1.00; CI range, .97-1.02; P range, .47-.65).

CONCLUSIONS

Dynamic metaplasia rather than the sheer extent of ectopy appears to increase risk for incident HPV16 in healthy young women. This in vivo observation is consistent with the HPV life cycle, during which host cell replication and differentiation supports viral replication.

Intravaginal ring delivery of tenofovir disoproxil fumarate for prevention of HIV and herpes simplex virus infection

OBJECTIVES

A safe and effective topical prevention strategy will likely require sustained delivery of potent antiviral drugs and a delivery system that simultaneously maximizes drug distribution and overcomes the behavioural challenges related to adherence. Activity against HIV and herpes simplex virus (HSV) would be advantageous, given the epidemiological link between the two pathogens. We hypothesize that tenofovir disoproxil fumarate (tenofovir DF), a prodrug of tenofovir, may be more potent than tenofovir and ideal for sustained intravaginal ring (IVR) delivery.

METHODS

The anti-HIV and anti-HSV activity of tenofovir and tenofovir DF were assessed in cell and explant models. Cumulative tenofovir DF release and stability from polyether urethane (PEU), ethylene-co-vinyl acetate (EVA) and silicone IVRs were compared, and the activity and safety of drug released were evaluated in cervical explants and in a polarized dual-chamber model.

RESULTS

Tenofovir DF inhibited HIV and HSV at ≈ 100-fold lower concentrations than tenofovir and retained activity in the presence of semen. PEU rings delivered >1 mg/day of tenofovir DF for 30 days. Pre-treatment of cervical explants with 10 μg/mL tenofovir DF or eluants from PEU minirings resulted in >90% inhibition of HIV and reduced HSV-2 yields by 2.5 log. Tenofovir DF and eluants did not prevent cell growth or polarization, or have any deleterious effects on an epithelial barrier.

CONCLUSIONS

The findings support the development of a PEU tenofovir DF ring, which may provide potent and sustained protection against HIV and HSV.

Pregnancy in HIV-infected teenagers in London

OBJECTIVE

The aim of the study was to describe pregnancies in HIV-infected teenagers.

METHODS

A review of the case notes of HIV-infected pregnant teenagers aged 13-19 years from 12 London hospitals was carried out for the period 2000-2007.

RESULTS

There were 67 pregnancies in 58 young women, of whom one was known to have acquired HIV vertically. The overall mother-to-child transmission (MTCT) rate of HIV was 1.5% (one of 66). There were 66 live births. Median ages at HIV diagnosis and conception were 17 and 18 years, respectively. Sixty-three per cent of women were diagnosed with HIV infection through routine antenatal screening. Eighty-two per cent of pregnancies (41 of 50) were unplanned, with 65% of women (26 of 40) using no contraception. Forty-three per cent of the women (20 of 46) had a past history of a sexually transmitted infection (STI). In 63 pregnancies, antiretroviral therapy was started post-conception, with prevention of HIV MTCT the only indication in 81% of cases. Fifty-eight per cent of those on highly active antiretroviral therapy (HAART) had an undetectable HIV viral load by delivery. Eighty-seven per cent were uncomplicated pregnancies. Seventy-one per cent delivered by Caesarean section and 21% (14 of 64) had a preterm delivery (<37 weeks). In the 12 months after delivery, 45% of women received contraceptive advice and 25% of women became pregnant again.

CONCLUSION

Obstetric and virological outcomes were favourable in this group of HIV-infected young women. However, the majority of pregnancies were unplanned with poor documentation of contraception use and advice and low rates of STI screening. A quarter of women conceived again within 12 months of delivery. Effective measures to reduce STIs, unplanned pregnancies and onward HIV transmission in HIV-infected teenagers are needed.

Herpes simplex virus-induced epithelial damage and susceptibility to human immunodeficiency virus type 1 infection in human cervical organ culture

Normal human premenopausal cervical tissue has been used to derive primary cell populations and to establish ex vivo organ culture systems to study infections with herpes simplex virus (HSV-1 or HSV-2) and human immunodeficiency virus type 1 (HIV-1). Infection with either HSV-1 or HSV-2 rapidly induced multinuclear giant cell formation and widespread damage in mucosal epithelial cells. Subsequent exposure of the damaged mucosal surfaces to HIV-1 revealed frequent co-localization of HSV and HIV-1 antigens. The short-term organ culture system provides direct experimental support for the epidemiological findings that pre-existing sexually transmitted infections, including primary and recurrent herpes virus infections at mucosal surfaces, represent major risk factors for acquisition of primary HIV-1 infection. Epithelial damage in combination with pre-existing inflammation, as described here for overtly normal human premenopausal cervix, creates a highly susceptible environment for the initiation and establishment of primary HIV-1 infection in the sub-mucosa of the cervical transformation zone.

Coming of age: reconstruction of heterosexual HIV-1 transmission in human ex vivo organ culture systems

Heterosexual transmission of human immunodeficiency virus-1 (HIV-1), from men to women, involves exposure to infectious HIV-1 in semen. Therefore, the cellular and molecular processes that underlie HIV-1 transmission are closely interconnected with fundamental principles of human reproductive biology. Human ex vivo organ culture systems allow experimental reconstruction of HIV-1 transmission, using human semen and premenopausal cervicovaginal mucosal tissue, with specific emphasis on the progression from exposure to development of primary HIV-1 infection. Clearly, an isolated piece of human tissue cannot duplicate the full complexity of events in natural infections, but with correct observation of conventional medical and ethical standards, there is no opportunity to study HIV-1 exposure and primary infection in young women. Human mucosal organ cultures allow direct study of HIV-1 infection in a reproducible format while retaining major elements of complexity and variability that typify community-based HIV-1 transmission. Experimental manipulation of human mucosal tissue both allows and requires acquisition of new insights into basic processes of human mucosal immunology. Expanding from the current foundations, we believe that human organ cultures will become increasingly prominent in experimental studies of HIV-1 transmission and continuing efforts to prevent HIV-1 infection at human mucosal surfaces.

Attitudes and beliefs about anti-retroviral therapy are associated with high risk sexual behaviors among the general population of Kisumu, Kenya

Attitudes and beliefs about antiretroviral therapy (ART) may affect sexual risk behaviors among the general population in sub-Saharan Africa. We performed a cross-sectional population-based study in Kisumu, Kenya to test this hypothesis in October 2006. A total of 1655 participants were interviewed regarding attitudes and beliefs about ART and their sexual risk behaviors. The majority of participants, (71%) men and (70%) women, had heard of ART. Of these, 20% of men and 29% of women believed ART cures HIV. Among women, an attitude that "HIV is more controllable now that ART is available" was associated with sex with a non-spousal partner, increased lifetime number of sexual partners as well as a younger age at sexual debut. No significant associations with this factor were found among men. The belief that "ART cures HIV" was associated with younger age of sexual debut among women. The same belief was associated with an increased likelihood of exchanging sex for money/gifts and decreased likelihood of condom use at last sex among men. These findings were most significant for people aged 15-29 years. In high HIV seroprevalence populations with expanding access to ART, prevention programs must ensure their content counteracts misconceptions of ART in order to reduce high risk sexual behaviors, especially among youth.

Hormonal contraception and area of cervical ectopy: a longitudinal assessment

BACKGROUND

The effect of combined oral contraceptives (COCs) and depot-medroxyprogesterone acetate (DMPA) on the area of cervical ectopy is not well understood.

STUDY DESIGN

From 1996 to 1999, we recruited women not using hormonal contraception from two family planning centers in Baltimore, MD. Upon study entry and 3, 6 and 12 months after the initial visit, participants were interviewed and received visual cervical examinations with photography. Ectopy was measured from digitized photographs and was analyzed both continuously and categorically (small [≤0.48 cm(2)] vs. large [>0.48 cm(2)]).

RESULTS

Of 1003 enrolled women, 802 returned for at least one follow-up visit. At 12 months, the numbers of women using COCs, DMPA or no hormonal method at least 50% of the time since the prior visit were 230, 76 and 229, respectively. After multivariable adjustment, COC use (vs. no hormonal use) was associated with large area of ectopy (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.0-3.3). No significant relationship was observed between DMPA and large area of ectopy (OR: 0.5, 95% CI: 0.2-1.3). The incidence of large area of ectopy by contraceptive exposure (COC, DMPA or no hormonal method) was 17.4 (CI: 11.8-24.6), 10.9 (CI: 4.4-22.4) and 4.6 (CI: 2.2-8.4) per 100 woman-years, respectively.

CONCLUSIONS

Use of COCs, but not DMPA, was associated with large area of cervical ectopy. Area of ectopy at baseline was the strongest predictor of area of ectopy at follow-up.

HIV sexual transmission and microbicides

Pathogens often rely on the contacts between hosts for transmission. Most viruses have adapted their transmission mechanisms to defined behaviours of their host(s) and have learned to exploit these for their own propagation. Some viruses, such as HIV, the human papillomavirus (HPV), HSV-2 and HCV, cause sexually transmitted infections (STIs). Understanding the transmission of particular viral variants and comprehending the early adaptation and evolution is fundamental to eventually inhibiting sexual transmission of HIV. Here, we review the current understanding of the mechanisms of sexual transmission and the biology of the transmitted HIV. Next, we present a timely overview of candidate microbicides, including past, ongoing and future clinical trials of HIV topical microbicides.

Cervico-vaginal tissue ex vivo as a model to study early events in HIV-1 infection

Vaginal intercourse remains the most prevalent route of infection of women. In spite of many efforts, the detailed mechanisms of HIV-1 transmission in the female lower genital tract remain largely unknown. With all the obvious restrictions on studying these mechanisms in humans, their understanding depends on the development of adequate experimental models. Isolated cell cultures do not faithfully reproduce important aspects of cell-cell interactions in living tissues and tissue responses to pathogens. Explants and other types of ex vivo tissue models serve as a bridge between cell culture and tissues in vivo. Herein, we discuss various cervico-vaginal tissue models and their use in studying HIV vaginal transmission and consider future directions of such studies.

Association of age at first sex with HIV-1, HSV-2, and other sexual transmitted infections among women in northern Tanzania

BACKGROUND

To examine the association between age at first sex and the prevalence of sexually transmitted infections (STIs), including HIV-1 and HSV-2, in women in Moshi urban district, northern Tanzania.

METHODS

A total of 2019 women aged 20 to 44 were randomly selected in a 2-stage sampling from Moshi urban district, northern Tanzania. Information on demographics and sexual behaviors were obtained. Blood and urine samples were drawn for testing of HIV-1, HSV-2, and other STIs.

RESULTS

Women who had their first sexual intercourse at age between 18 and 19 (OR = 0.66; 95% CI = 0.50-0.86) or 20+ (OR = 0.46; 95% CI = 0.36-0.60) were less likely to have STIs, including HIV-1 and HSV-2, than women who had their first intercourse before their 18th birthday. The hazards of having had first sex at an earlier age were significantly higher for women who tested positive for STIs (HR = 1.52; 95% CI: 1.37-1.69) or had STI symptoms (HR = 1.17; 95% CI: 1.05-1.30). Early age at first sex was associated with having a regular noncohabiting partner (HR = 1.40; 95% CI: 1.23-1.58), female circumcision (HR = 1.20; 95% CI: 1.02-1.40), and coercion at first intercourse (HR = 1.47; 95% CI: 1.15-1.89).

CONCLUSIONS

In sub-Saharan Africa, where the prevalence of HIV and other STIs is high, a better understanding of the determinants of the age at first sex is crucial for HIV/STI prevention programs. Prevention programs should not only aim at delaying the age at first sex but also address factors leading to early age at first sex.

Management of adolescents who have abnormal cytology and histology

Adolescents have been shown to have the highest rates of human papillomavirus (HPV) infection. The cause is likely a combination of sexual risk behavior and biologic vulnerability. Most HPV and its associated abnormal cytology are transient, with frequent clearance of HPV and the lesion. These findings have resulted in new strategies, including observation, for adolescents who have abnormal cytology. For cytologic atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions, adolescents should be followed with cytology at 1-year intervals for up to 2 years before referral for colposcopy is necessary. For biopsy-proved cervical intraepithelial neoplasia (CIN) 1, management is similar, with yearly cytology indefinitely or until high-grade squamous intraepithelial lesions or CIN 2,3 develops. CIN 2,3 in compliant adolescents can be managed with 6-month cytology and colposcopy up to 2 years.

Factors that influence the rate of epithelial maturation in the cervix in healthy young women

PURPOSE

To examine the longitudinal changes in the epithelial topography of the cervix in healthy young women; and to determine the sociodemographic, behavioral, and biological factors associated with the rate of cervical epithelial maturation.

METHODS

Healthy young women were enrolled from October 2000 to September 2002 as part of a larger study of human papillomavirus (HPV). At interval visits, interviews, infection testing, and colpophotography (3% acetic acid; 10x, 16x magnifications) were performed. Areas of total cervical face and cervical immaturity, defined as columnar and early squamous metaplasia, were quantitatively measured using computerized planimetry. Cervical immaturity was expressed as percentage of total cervical face. This analysis includes the first consecutive 145 women with greater than 10% immaturity at baseline. The rate of cervical maturation was defined as change in percent-immaturity. Predictors included sociodemographics, sexual behaviors, and infections. Data analyses included multivariate generalized linear models with repeated measures.

RESULTS

The baseline mean age was 17.8 years. Colpophotographs were available from 815 total visits, representing 2.7 years mean follow-up per woman and 5.9-month mean intervals. Women began the study with a median of 39% immaturity and ended with 8% immaturity. After adjusting for time and baseline percent-immaturity, an increased rate of cervical maturation was associated with oral contraceptive pill use (parameter estimate -.023, p =.04) and smoking (-.039, p =.01).

CONCLUSIONS

Cervical maturation was documented during relatively short time periods for the vast majority of these women. Oral contraceptive pills and smoking may accelerate the maturational process, representing increased cell proliferation and thus a possible greater vulnerability to HPV.

Evidence for benefits from treating cervical ectopy: literature review

CONTEXT AND PURPOSE

Uterine cervical ectopy (cervical erosion) is today considered to be a physiological condition, but there still seems to be a strong tendency towards treating it. The purpose of this study was to review the medical literature for evidence regarding benefits from treating cervical ectopy.

METHODS

The following databases were reviewed: Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica Database (Embase), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) and Cochrane Library databases. In addition, six medical textbooks were consulted.

RESULTS

The review showed that: 1) there is probably an association between ectopy and higher risk of Chlamydia trachomatis, human papillomavirus and human immunodeficiency virus infection; 4) there is probably an association between ectopy and cervical intraepithelial neoplasia; 5) there is an association between ectopy and mucous discharge and nocturia; and 6) there is no evidence of an association between ectopy and cervical cancer, or of protection against cervical cancer associated with ectopy treatment.

CONCLUSIONS

1) No data were found in the medical literature to support routine treatment for ectopy; 2) Treatment could be recommended for symptom relief, but more symptoms are attributed to ectopy than could be demonstrated in a controlled study; 3) Further studies to test the hypothesis of protection against cervical cancer associated with treatment are necessary.

Immunization of early adolescent females with human papillomavirus type 16 and 18 L1 virus-like particle vaccine containing AS04 adjuvant

PURPOSE

In female individuals 15-25-years of age, the AS04-containing human papillomavirus (HPV)-16/18 vaccine is highly immunogenic and provides up to 100% protection against HPV-16/18 persistent infection and associated cervical lesions up to 4.5 years. Optimal cervical cancer prevention will require prophylactic vaccination against oncogenic HPV 16 and 18 before the onset of sexual activity in early adolescent girls. To establish the feasibility of vaccination in girls 10-14 years of age, we compared the immunogenicity and safety in early adolescent female individuals to those 15-25 years in whom vaccine efficacy has been demonstrated.

METHODS

We enrolled 773 female participants aged 10-14 years and 15-25 years to receive the HPV-16/18 L1 VLP AS04 vaccine, which was administered at months 0, 1, and 6. Serum samples were collected at months 0 and 7; antibodies to HPV 16 and 18 VLPs were measured by enzyme-linked immunosorbent assay. Vaccine safety was assessed at 7 or 30 days after each dose; serious adverse events were recorded during the entire study period.

RESULTS

Both age groups achieved 100% seroconversion for HPV 16 and 18. Participants in the group aged 10-14 years were not only noninferior to those 15-25 years in terms of HPV 16 and 18 seroconversion rates but also had approximately twice as high geometric mean titers. The vaccine was generally safe and well tolerated.

CONCLUSIONS

These findings suggest that HPV vaccination during early adolescence is generally safe, well tolerated, and highly immunogenic. The observed higher antibody titers in the group 10-14 years of age are likely to result in longer antibody persistence. Overall, these data support the implementation of prophylactic HPV vaccination in this age group.

Reproductive health of adolescent girls perinatally infected with HIV

OBJECTIVES

We sought to describe the reproductive health of adolescent girls perinatally infected with HIV.

METHODS

We estimated the incidence of first pregnancy, genital infections, and abnormal cervical cytology for 638 girls aged 13 years and older in the Pediatric AIDS Clinical Trials Group protocol 219C.

RESULTS

Thirty-eight girls became pregnant, for a first pregnancy rate of 18.8/1000 person-years; 7 of these girls had additional pregnancies (95% confidence interval [CI]=13.3, 25.7). Thirty-two pregnancies resulted in live births. All girls received antiretroviral therapy during pregnancy. One infant was HIV infected, 29 were uninfected, and 2 had unknown infection status, for a rate of mother-to-child transmission of HIV in infants with known infection status of 3.3% (95% CI=0.1, 18.6). Condylomata and trichomoniasis were the most frequent genital infections. Forty-eight (47.5%) of 101 girls with Papanicolaou test examinations had abnormal cervical cytology, including atypical cells of undetermined significance (n=18), low-grade squamous intraepithelial lesions (SIL; n=27), and high-grade SIL (n=3). Many abnormalities persisted despite intervention.

CONCLUSIONS

Pregnancy rates were lower and cervical abnormalities were higher than among non-HIV-infected adolescents. These findings underscore the importance of Papanicolaou tests and promotion of safer sexual practices in this population.

Nested Case–Control Study of Cervical Mucosal Lesions, Ectopy, and Incident HIV Infection Among Women in Cape Town, South Africa

OBJECTIVE

The objective of this study was to test whether cervical mucosal lesions and ectopy increase women's susceptibility to HIV infection.

STUDY DESIGN

HIV-seronegative women ages 35 to 65 years (n = 5773) enrolled into a cervical cancer screening trial were followed for up to 36 months. All HIV seroconverters (n = 86) in the cohort were compared with randomly selected controls (n = 324) who did not seroconvert. Magnified photographs of the cervix taken during speculum examination at enrollment were evaluated for cervical mucosal lesions and ectopy using standard criteria.

RESULTS

The presence of mucosal lesions (observed among 19% of controls) was associated with increased risk of HIV seroconversion (adjusted odds ratio [AOR] = 1.93; 95% confidence interval [CI] = 1.07-3.48). Ectopy extending over >20% of the cervix was also associated with HIV seroconversion (AOR = 2.18; 95% CI = 1.01-4.69).

CONCLUSIONS

Visible lesions of cervical mucosa and cervical ectopy may be markers of increased susceptibility to HIV infection among women. Protection of the mucosa of the cervix may provide an important approach for new HIV prevention technologies.

A brief, low-cost, theory-based intervention to promote dual method use by black and Latina female adolescents: a randomized clinical trial

HIV/AIDS disproportionately affects young women of color. Young women who use hormonal contraception are less likely to use condoms. Brief, inexpensive HIV-prevention interventions are needed for high-volume clinics. This study was a randomized clinical trial of two interventions: (a) a video made for this study and (b) an adaptation of Project RESPECT counseling. Four hundred Black and Latina teenage women completed a questionnaire about their sexual behaviors and were randomly assigned to (a) see the video, (b) get counseling, (c) see the video and get counseling, or (d) receive usual care. At 3-month follow-up, those who saw the video and received counseling were 2.5 times more likely to have used a condom at last intercourse with their main partner than teens in the usual care group. These differences did not persist at 12-month follow-up. This suggests that a brief intervention can positively affect condom use in the short term.

Young age is a risk factor for HIV among female sex workers--an experience from India

OBJECTIVE

A cross-sectional community-based study was conducted among brothel-based sex workers of West Bengal, eastern India, to study the prevalence of HIV and associated risk factors.

METHODS

Unlinked anonymous HIV testing was performed on 2076 sex workers. Of these, 558 were interviewed using a pre-tested questionnaire to study their risk factors.

RESULTS

Overall HIV sero-prevalence was 5.9%. All infections were HIV-1, except that four sex workers from Kolkata were infected with HIV-2. Surprisingly, HIV infection was much higher (12.5%) in younger sex workers (age < or =20 years) compared with older age groups (5.4%) (P=0.002; odds ratio 2.40, 95% CI: 1.29-4.38).

CONCLUSIONS

This could be associated with larger areas of cervical ectopy of younger sex workers who are subjected to repeated trauma during sexual intercourse, facilitating higher HIV transmission. Behavioral factors may increase a young sex worker's risk of acquiring HIV infection, including professional immaturity with clients, which might lead to more unprotected sex. HIV status was associated with other sexually transmitted infection in the previous year but was not associated with literacy status, daily income, duration of sex work, number of clients entertained per day, entertaining clients outside a brothel (in a hotel), and reported condom use.

Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms

Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.

Biological and hormonal markers of chlamydia, human papillomavirus, and bacterial vaginosis among adolescents attending genitourinary medicine clinics

OBJECTIVE

To assess maturity indices, menstrual patterns, hormonal factors, and risk of adolescent genital tract infections.

METHODS

Cross sectional study in three genitourinary medicine clinics. Females 17 years or less, within 5 years of menarche, or reporting oligo-amenorrhoea were screened for genital tract infections and menstrual cycle characteristics determined. The outcome measures were risk factors associated with chlamydia, human papillomavirus (HPV DNA) and bacterial vaginosis (BV), separately and pooled. Correlations between estrone-3-glucuronide (E3G) and pregnanediol-3alpha-glucuronide (P3G) hormone concentrations and chlamydia, HPV, and BV.

RESULTS

Among 127 adolescents, HPV was present in 64.4% (95% CI: 54.5 to 74.3), BV in 33.9% (19.1 to 34.5), and chlamydia in 26.8% (19.1 to 34.5). Breast maturity, oligomenorrhoea, and older gynaecological age were associated with lower risk of all infections. After adjustment for calendar age, race, and behavioural factors, gynaecological age remained significant (OR = 0.7, 0.6-0.9; p = 0.008). Behavioural risk factors differed by infection. Smoking was protective for HPV (OR = 0.1, 0.0 to 0.9; p = 0.007), and a recent new partner for chlamydia (OR = 0.3, 0.1 to 0.9; p = 0.024). Sex during menses was associated with increased BV risk (OR = 3.3, 1.5 to 7.2; p = 0.003). Chlamydia was higher among adolescents who used emergency contraception (2.5; 1.1 to 5.9, p = 0.029) and lower among those using condoms at last sex (OR = 0.3, 0.1 to 0.9; p = 0.015). Among 25 adolescents not using hormonal contraceptives, 15 had disturbed or anovulatory cycles. Chlamydia risk was inversely associated with P3G concentrations (Mann-Whitney; p = 0.05).

CONCLUSIONS

Adolescents engaging in high risk behaviour at a young gynaecological age are susceptible to multiple infections. Adolescent clinical assessment should include gynaecological age.

Human papillomavirus infection and cervical ectopy

OBJECTIVES

To investigate the prevalence of human papillomavirus (HPV), and HPV type 16 (HPV16) infection in cervical ectopy, and the presence of anti-HPV16 secretory IgA (sIgA) antibodies.

METHODS

DNA from patients with cervical ectopy (n=218), HPV-associated lesions (n=111), and controls without evidence of cervical ectopy or HPV infection (n=93) were analyzed by PCR for the presence of HPV and HPV16. The presence of mucosal sIgA antibodies against HPV16 capsid antigens (VLP) was assayed in cervical mucus by ELISA.

RESULTS

Prevalence of HPV DNA was higher in cervical ectopy than in controls (P=0.04; OR=2.06; 95% CI 0.99-4.33). HPV16 was 6.3 times more prevalent in cervical ectopy than in controls. Anti-HPV16 sIgA were detected more frequently in cervical ectopy patients than in controls (P=0.0004).

CONCLUSIONS

Cervical ectopy correlates with HPV infection. HPV16 is highly prevalent in cervical ectopy. sIgA antibodies against HPV16 capsids are generated in patients with cervical ectopy.

Early age of first sex: a risk factor for HIV infection among women in Zimbabwe

OBJECTIVE

To explore the relationship between early age of coital debut (15 years of age or younger) and risk for HIV infection among sexually active urbanized Zimbabwean women.

DESIGN

Cross-sectional analysis of screening data from a cohort study.

METHODS

Sexually active women aged 18-35 years were recruited from public sector family planning clinics in and around Harare, Zimbabwe between November 1999 and September 2002. They received a brief behavioral interview and HIV testing. Of the 4675 women screened, 4393 (94%) had complete data on sexual behaviors and HIV serostatus, and were included in this analysis.

RESULTS

HIV prevalence in this sample was 40.1%. The median age of coital debut was 18 years and 11.8% of women reporting having experienced coital debut at age 15 or younger. Women with early coital debut had a significantly higher risk profile, including multiple lifetime partners and not completing high school. In binary generalized linear regression models HIV risk was increased for women reporting early age of coital debut (relative hazard, 1.30; 95% confidence interval, 1.13-1.50), controlling for duration of sexual activity and current age; this effect was attenuated somewhat after controlling for other factors such as number of sexual partners.

CONCLUSIONS

Our results show that early coital debut is a significant predictor of prevalent HIV infection independent of other identified factors in this population. HIV prevention strategies should include delaying the age of first coitus and should address the barriers that may prevent young women from so doing.

Sexually transmitted infections among HIV infected and HIV uninfected high-risk youth in the REACH study. Reaching for Excellence in Adolescent Care and Health

This review presents the findings of published research in the Reaching for Excellence in Adolescent Care and Health (REACH) Project on sexually transmitted infections (STIs) within the context of the project's scientific agenda. Methods employed in the study for specimen collection, management, and laboratory analysis are presented. This review presents published analyses of cross-sectional data; longitudinal analyses are underway. In addition, baseline prevalence data on selected STIs and sexual risk profiles of the subjects in REACH are presented. High STI rates were evident in both human immunodeficiency virus (HIV) infected and uninfected youth of both genders regardless of sexual orientation. High infection rates at baseline suggest that prevention-oriented programs for risk reduction among adolescents should focus on both HIV infected and at-risk, uninfected youth.