Vaginal swabs versus lavage for detection of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women

The International Society for the Study of Vulvovaginal Disease Vaginal Wet Mount Microscopy Guidelines: How to Perform, Applications, and Interpretation

OBJECTIVES

The aims of the study were to assess the available literature concerning the indications, performance, technique, and classification of wet mount microscopy (WMM) and to establish evidence-based recommendations.

METHODS

Literature review from the main scientific databases was performed by the ad hoc "Vaginitis and Microbiome Committee" of the International Society for the Study of Vulvovaginal Disease. The document was approved by the executive council and membership of the International Society for the Study of Vulvovaginal Disease.

RESULTS

Available data are limited and usually of low level of evidence. Nevertheless, it shows that WMM is capable of reducing misdiagnosis, overtreatment, and undertreatment of vaginal conditions. It has an excellent performance for the diagnosis of bacterial vaginosis and variable performance for trichomoniasis and candidiasis. It is the gold standard for aerobic vaginitis/desquamative inflammatory vaginitis. Currently, there is no recommendation to use WMM in the screening of asymptomatic women.The use of phase contrast is recommended to improve performance and reproducibility. Sampling location, devices, and technique have an impact on the results.Available scoring and classification scores have significant limitations.

CONCLUSIONS

Wet mount microscopy is a point-of-care, inexpensive, and fast technique that, with practice, can be mastered by office clinicians. It should be considered a basic skill in the curricula of gynecology and obstetrics residencies. Recommendations are provided on sampling, reading, and scoring.

A cross-sectional analysis of Trichomonas vaginalis infection among heterosexual HIV-1 serodiscordant African couples

OBJECTIVES

Trichomonas vaginalis is the most prevalent curable STI worldwide and has been associated with adverse health outcomes and increased HIV-1 transmission risk. We conducted a cross-sectional analysis among couples to assess how characteristics of both individuals in sexual partnerships are associated with the prevalence of male and female T. vaginalis infection.

METHODS

African HIV-1 serodiscordant heterosexual couples were concurrently tested for trichomoniasis at enrolment into two clinical trials. T. vaginalis testing was by nucleic acid amplification or culture methods. Using Poisson regression with robust standard errors, we identified characteristics associated with trichomoniasis.

RESULTS

Among 7531 couples tested for trichomoniasis, 981 (13%) couples contained at least one infected partner. The prevalence was 11% (n=857) among women and 4% (n=319) among men, and most infected individuals did not experience signs or symptoms of T. vaginalis. Exploring concordance of T. vaginalis status within sexual partnerships, we observed that 61% (195/319) of T. vaginalis-positive men and 23% (195/857) of T. vaginalis-positive women had a concurrently infected partner. In multivariable analysis, having a T. vaginalis-positive partner was the strongest predictor of infection for women (relative risk (RR) 4.70, 95% CI 4.10 to 5.38) and men (RR 10.09, 95% CI 7.92 to 12.85). For women, having outside sex partners, gonorrhoea, and intermediate or high Nugent scores for bacterial vaginosis were associated with increased risk of trichomoniasis, whereas age 45 years and above, being married, having children and injectable contraceptive use were associated with reduced trichomoniasis risk. Additionally, women whose male partners were circumcised, had more education or earned income had lower risk of trichomoniasis.

CONCLUSIONS

We found that within African HIV-1 serodiscordant heterosexual couples, the prevalence of trichomoniasis was high among partners of T. vaginalis-infected individuals, suggesting that partner services could play an important role identifying additional cases and preventing reinfection. Our results also suggest that male circumcision may reduce the risk of male-to-female T. vaginalis transmission.

The influence of ART on the treatment of Trichomonas vaginalis among HIV-infected women

OBJECTIVE

Among women who are human immunodeficiency virus positive (HIV+), both prevalent and persistent infections with Trichomonas vaginalis (TV) are common. TV has been shown to increase vaginal shedding of HIV, which may influence HIV sexual and perinatal transmission, making prevention important. In 1 cohort of HIV+ women in Kenya, antiretroviral therapy (ART) use, mostly nevirapine based, was associated with lower cure rates of TV for single-dose therapy. Our goal was to repeat this study in a US-based cohort of HIV+/TV+ women and compare outcomes to those with multidose therapy.

METHODS

A secondary data analysis was performed on a multicentered cohort of HIV+/TV+ women who were randomized to single-dose (2 grams) or 7-day (500 mg twice daily) multidose metronidazole (MTZ) treatment. Test of cure visit, via culture, occurred 6-12 days after treatment completion. Information was collected on sex partner treatment and sexual exposures. Persistent TV infection rates were compared for women on ART at baseline vs not on ART.

RESULTS

Of the 226 women included, those on ART had more treatment failures than women not on ART (24/146 [16.4%] vs 5/80 [6.3%]; P = .03). When stratified by treatment arm, more treatment failures were seen in the single-dose arm (17/73 [23.3%] vs 3/39 [7.7%]; P = .05) than in the multidose arm (7/73 [9.6%] vs 2/41 [4.8%]; P = .39).

CONCLUSIONS

ART usage was associated with a higher TV persistent infection rate among those receiving the single-dose treatment, but not the multidose, providing more evidence that multidose should be the preferred treatment for HIV+ women.

Trichomonas vaginalis infection among women receiving gynaecological care at an Alabama HIV Clinic

OBJECTIVE

Trichomoniasis vaginalis is a risk factor for the acquisition and transmission of HIV. The objective of this study was to determine the prevalence of T vaginalis (using culture) among HIV-infected women receiving gynaecological care at an university HIV clinic in Alabama in addition to predictors of infection.

METHODS

Electronic medical record review of women presenting to the clinic for gynaecological care during 2006-2012 was performed. Demographic and sexual history data was abstracted in addition to absolute CD4 cell count, HIV-1 viral load and sexually transmitted infection (STI) (including T vaginalis) testing results. Analysis was conducted using Stata V.12.

RESULTS

T vaginalis was prevalent in 17.4% (83/478) of HIV-infected women; other STIs were less prevalent. Among these women, 384 presented for routine STI screening, of which 12% (46/384) were T vaginalis-infected. Younger age, African-American race, lifetime history of tobacco and drug abuse, lack of HIV therapy, HIV-1 viral load >400 copies/ml, and report of seeking gynaecological care for reasons other than routine STI screening (ie, having symptoms) were significant predictors of T vaginalis in univariate analysis. Age, African American race, and report of seeking gynaecological care for reasons other than routine STI screening remained associated with T vaginalis in multivariable analysis.

CONCLUSIONS

T vaginalis remains highly prevalent among HIV-infected women, a proportion of which may be asymptomatic. If left undiagnosed and untreated, these women may be more likely to transmit HIV. Increased emphasis on screening for high risk sexual behaviours, testing for T vaginalis, and risk reduction counselling is necessary for all HIV-infected women.

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

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

Patient-delivered partner treatment and Trichomonas vaginalis repeat infection among human immunodeficiency virus-infected women

BACKGROUND

Repeat infections with Trichomonas vaginalis (TV) among human immunodeficiency virus (HIV)-infected women are common and may increase the risk of HIV transmission. Patient delivered partner treatment (PDPT) has been shown to reduce repeat infections of other sexually transmitted diseases. The purpose of this study was to evaluate adherence to PDPT and possible causes of repeat TV infection among HIV-infected women.

METHODS

A multicentered cohort study was conducted in 3 US cities. Women coinfected with HIV and TV were treated with metronidazole and given treatment to deliver to all reported sex partners. A test-of-cure visit was conducted 6 to 12 days post index treatment completion and behavioral data were collected.

RESULTS

Of 252 women (mean age = 40 years, s.d. 9.1) enrolled, 92.5% were black, 26.2% had CD4 cell counts <200/mm(3), 34.1% had plasma viral loads >10,000 copies, 58.3% were taking antiretrovial therapy, and 15.1% had multiple partners. Of the 183 women with partners at baseline, 75.4% provided PDPT to all partners and 61.7% reported they were sure all of their partners took the medication. Factors associated with not giving medications to all partner(s) were multiple sex partners, being single, and having at least one partner unaware of the index woman's HIV status. At test-of-cure, 10.3% were TV-positive and 16.7% reported having sex since baseline. Of the 24 repeat infections, 21 (87.5%) reported adherence to medication and no sexual exposure.

CONCLUSION

HIV-infected women with TV reported high adherence to PDPT, and treatment failure was the most common probable cause of repeat infection.

The influence of bacterial vaginosis on the response to Trichomonas vaginalis treatment among HIV-infected women

OBJECTIVE

Trichomonas vaginalis (TV) is common in HIV+ women, and host factors may play a role in TV treatment outcomes. The purpose of this study was to examine the influence of bacterial vaginosis (BV) on the response to TV treatment among HIV+ women.

METHODS

A secondary analysis was conducted of a clinical trial which randomised HIV+/TV+ women to metronidazole (MTZ) treatment: 2 g (single-dose) versus 7 day 500 mg twice daily (multidose). BV was classified using Nugent scores from baseline Gram stains. Women were recultured for TV at test-of-cure (TOC) and again at 3 months if TV-negative at TOC. Repeat TV infection rates were compared for women with a baseline TV/BV coinfection versus baseline TV infection only, and stratified by treatment arm.

RESULTS

Among 244 HIV+/TV+ women (mean age=40.3, ±9.5; 92.2% African-American), the rate of BV was 66.8%. Women with BV were more likely to report douching and ≥1 recent sex partners. HIV+ women with baseline TV/BV coinfection were more likely to be TV-positive at TOC than women with baseline TV infection only (RR 2.42 (95% CI 0.96 to 6.07; p=0.05)). When stratified by treatment arm, the association was only found in the single-dose arm (p=0.02) and not in the multidose arm (p=0.92). This interaction did not persist at 3 months.

CONCLUSIONS

For HIV+/TV+ women, the rate of BV was high, and BV was associated with early failure of the MTZ single-dose treatment for TV. Biological explanations require further investigation.

A randomized treatment trial: single versus 7-day dose of metronidazole for the treatment of Trichomonas vaginalis among HIV-infected women

OBJECTIVE

To determine if the metronidazole (MTZ) 2-gm single dose (recommended) is as effective as the 7-day 500 mg twice a day dose (alternative) for treatment of Trichomonas vaginalis (TV) among HIV+ women.

METHODS

Phase IV randomized clinical trial; HIV+ women with culture confirmed TV were randomized to treatment arm: MTZ 2-gm single dose or MTZ 500 mg twice a day 7-day dose. All women were given 2-gm MTZ doses to deliver to their sex partners. Women were recultured for TV at a test-of-cure (TOC) visit occurring 6-12 days after treatment completion. TV-negative women at TOC were again recultured at a 3-month visit. Repeat TV infection rates were compared between arms.

RESULTS

Two hundred seventy HIV+/TV+ women were enrolled (mean age = 40 years, ±9.4; 92.2% African American). Treatment arms were similar with respect to age, race, CD4 count, viral load, antiretroviral therapy status, site, and loss-to-follow up. Women in the 7-day arm had lower repeat TV infection rates at TOC [8.5% (11 of 130) versus 16.8% (21 of 125) (relative risk: 0.50, 95% confidence interval = 0.25, 1.00; P < 0.05)] and at 3 months [11.0% (8 of 73) versus 24.1% (19 of 79) (relative risk: 0.46, 95% confidence interval = 0.21, 0.98; P = 0.03)] compared with the single-dose arm.

CONCLUSIONS

The 7-day MTZ dose was more effective than the single dose for the treatment of TV among HIV+ women.

A distinct cellular profile is seen in the human endocervix during Chlamydia trachomatis infection

PROBLEM

The endocervix is a major target of Chlamydia trachomatis infection, but little is known about the immune repertoire in this tissue, or its response to these common bacteria.

METHOD OF STUDY

Using a cytobrush, we isolated cells from the endocervix of 20 women during C. trachomatis infection, and post-antibiotic treatment. Endocervical swabs and blood were taken in parallel. Endocervical cells were enumerated, and endocervical and blood T cells immunophenotyped. Chlamydia trachomatis was genotyped by sequence analysis of the OmpA gene, and quantified by culture.

RESULTS

Chlamydia trachomatis genotypes were D, E, F and Ia, and infectious burden varied considerably. Endocervical T cell and neutrophil numbers were highly elevated during infection, with both CD4 and CD8 T-cell subsets accumulating. Regardless of the presence or absence of infection, the endocervical cell infiltrate was dominated by effector memory T cells, and the numbers of CCR5 and CD103 expressing T cells was significantly higher than in the blood. Human leukocyte antigen (HLA-DR) expression by endocervical T cells was significantly increased during infection.

CONCLUSION

The human endocervix exhibits a distinct cellular response to C. trachomatis infection that can be longitudinally evaluated by cytobrush sampling. Infecting organisms can be sampled and analyzed in parallel.

Early repeated infections with Trichomonas vaginalis among HIV-positive and HIV-negative women

BACKGROUND

The purpose of the study was to examine whether early repeated infections due to Trichomonas vaginalis among human immunuodeficiency virus (HIV)-positive and HIV-negative women are reinfections, new infections, or cases of treatment failure.

METHODS

Women attending an HIV outpatient clinic and a family planning clinic in New Orleans, Louisiana, who had culture results positive for T. vaginalis were treated with 2 g of metronidazole under directly observed therapy. At 1 month, detailed sexual exposure and sexual partner treatment information was collected. Isolates from women who had clinical resistance (i.e., who tested positive for a third time after treatment at a higher dose) were tested for metronidazole susceptibility in vitro.

RESULTS

Of 60 HIV-positive women with trichomoniasis, 11 (18.3%) were T. vaginalis positive 1 month after treatment. The 11 recurrences were classified as 3 probable reinfections (27%), 2 probable infections from a new sexual partner (18%), and 6 probable treatment failures (55%); 2 of the 6 patients who experienced probable treatment failure had isolates with mild resistance to metronidazole. Of 301 HIV-negative women, 24 (8.0%) were T. vaginalis positive 1 month after treatment. The 24 recurrences were classified as 2 probable reinfections (8%) and 22 probable treatment failures (92%); of the 22 patients who experienced probable treatment failure, 2 had strains with moderate resistance to metronidazole, and 1 had a strain with mild resistance to metronidazole.

CONCLUSION

HIV-positive women were more likely to have sexual re-exposure than were HIV-negative women, although the rate of treatment failure was similar in both groups. High rates of treatment failure among both HIV-positive and HIV-negative women indicate that a 2-g dose of metronidazole may not be adequate for treatment of some women and that rescreening should be considered.

Frequent Douching and Clinical Outcomes Among HIV-Infected Women

OBJECTIVE

To determine the prevalence of douching among a cohort of HIV-infected women and to examine clinical outcomes associated with frequent douching-namely bacterial vaginosis, presence of a sexually-transmitted infections, and genital tract HIV-1 RNA shedding.

STUDY DESIGN

Participants included a concurrent cohort of 187 women attending an HIV outpatient clinic in New Orleans, LA. Subjects underwent clinical examinations and answered questions in a computer-assisted survey at each visit.

RESULTS

At baseline, 1-, and 3-month follow-ups, 64.2%, 56.5%, and 54.7% of women, respectively, indicated that they douched. In multivariable analyses, douching >1 time a month was independently associated with the outcomes of bacterial vaginosis and presence of a selected sexually transmitted infection (Trichomonas vaginalis, Neisseria gonorrhea, or Chlamydia trachomatis). Although not significant, women who douched >1 time a month were also twice as likely to have genital tract HIV-1 RNA shedding as nondouchers.

CONCLUSIONS

This is the first study performed in women infected with HIV to link a significant dose-response relationship between douching and the clinical outcomes of bacterial vaginosis and presence of a sexually transmitted infection, and to examine the association between douching and genital tract HIV-1 RNA shedding.

Comparison of a TaqMan-based real-time polymerase chain reaction with conventional tests for the detection of Trichomonas vaginalis

OBJECTIVE

To compare a TaqMan-based real-time polymerase chain reaction (PCR) with conventional PCR, culture, and wet-mount microscopy for the diagnosis of trichomoniasis in women.

METHODS

Vaginal swabs from 119 women were tested for Trichomonas vaginalis by wet mount and culture. Paired vaginal lavage and urine specimens were tested by conventional and real-time PCR.

RESULTS

Using an expanded "gold standard", defined as a positive culture result using vaginal swabs and/or a positive PCR test using TVK3/7 primers, the overall prevalence of T vaginalis in the study population was 65.5% (78/119). The detection rate of T vaginalis was 65.5% (78/119) and 36.9% (44/119) by conventional PCR using vaginal washings and urine specimens, respectively; 68.9% (82/119) by real-time PCR using vaginal washings and 61.3% (73/119) by real-time PCR using urine specimens. The sensitivities of conventional PCR using vaginal washings and urine and real-time PCR using vaginal washings and urine, compared with the gold standard were 100%, 56.4%, 100% and 76.7%, and the specificities of these tests were 100%, 97.6%, 82.9% and 97%, respectively.

CONCLUSIONS

The real-time PCR test proved to be significantly more sensitive than culture and wet-mount microscopy, although its specificity was slightly lower than these tests. In addition, it was more sensitive, rapid and less time consuming than conventional PCR for the detection of T vaginalis.

Sexually transmitted diseases in older adults

Health professionals are frequently reluctant to recognize or investigate the sexuality of their older patients. Thus, sexual health may never be addressed, even among older adults who come into frequent contact with health care professionals. As the dominant culture continues to shift toward a more realistic view of aging that supports the expression of sexuality among older adults, evaluation of sexual health will become a critical component of comprehensive assessment of the geriatric patient. This article reviews the clinical features and management of common sexually transmitted diseases in the older adult.