1
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Frechtling D, Chopra S, Ratnayake A, Kissinger PJ. The Association Between Human Immunodeficiency Virus and Bacterial Vaginosis and Metronidazole Treatment Failure for Trichomonas vaginalis. Sex Transm Dis 2024; 51:61-64. [PMID: 37921835 DOI: 10.1097/olq.0000000000001891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
BACKGROUND Trichomonas vaginalis (TV) is a common sexually transmitted infection. High rates of repeated infections have been observed, particularly among women living with human immunodeficiency virus (HIV). Trichomonas vaginalis frequently cooccurs with bacterial vaginosis (BV). The purpose of this study was to determine if coinfections with TV, BV, and HIV could lead to differential treatment failure outcomes. METHODS Data were pooled from 2 prior randomized control trials comparing 2 g oral single-dose versus 500-mg twice daily oral 7-day dose metronidazole for the treatment of TV in HIV infected and HIV uninfected women. Trichomonas vaginalis rates 1-month postcompletion of treatment were compared by arm, HIV and BV status after removing those who had sexual reexposure, and/or did not complete their treatment. RESULTS Data for 795 subjects were included in the study, of which 76 (9.6%) experienced treatment failure. In the final multivariable model, which included treatment dose, HIV status, and BV status, odds of treatment failure infection in the 7-day dose group were lower than the odds in the single dose group (odds ratio, 040; 95% confidence interval, 0.23-0.68). Treatment failure was lower in the multidose arm compared with single dose for both HIV-infected (4.0% vs 10.3%; P = 0.0568) and HIV-uninfected (7.3% vs 15.4%; P = 0.0037). Neither HIV nor BV was associated with higher treatment failure. CONCLUSIONS Human immunodeficiency virus infection and BV status did not significantly alter the rate of repeat infection for either single dose or 7-day dose metronidazole. Among all women, 7-day metronidazole lowered the odds of treatment failure.
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Affiliation(s)
- Dan Frechtling
- From the John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Shubam Chopra
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Aneeka Ratnayake
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Patricia J Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
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2
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Waltmann A, Thomas C, Duncan JA. The role of the genital microbiota in the acquisition and pathogenesis of sexually transmitted infections. Curr Opin Infect Dis 2023; 36:35-48. [PMID: 36729748 PMCID: PMC10500551 DOI: 10.1097/qco.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW There are an estimated 374 million new sexually transmitted infections (STIs) worldwide every year. Our review article examines the current evidence of how STI acquisition, transmission, and pathogenesis is impacted upon by the genital microbiota, with a focus on epidemiological, biochemical, and immunological features. RECENT FINDINGS At least in women, a genital microbiota dominated by lactobacilli has long been considered optimal for reproductive health, while depletion of lactobacilli may lead to a genital microenvironment dominated by anaerobic pathogens, which can manifest clinically as bacterial vaginosis. Recent research efforts have characterized genital microbiota composition in greater resolution, sometimes at species-level, using proteomics, metabolomics, and deep sequencing. This has enhanced our understanding of how specific microbiota members influence acquisition or clinical manifestation of STI pathogen infection. Other advances include a steady, though still slow, increase in the number of studies that sought to determine the genital (penile or urethral) microbiota of males and how it may impact that of their female partners' genital microbiota and risk of STI acquisition. Altogether, these data enabled us to explore the concept that genital microbiota may be sexually transmitted and influence pathogenesis and clinical presentation of other STI. SUMMARY With STI infection rates increasing worldwide, it is important now more than ever to find novel STI prevention strategies. Understanding if and how the genital microbiota is a modifiable risk factor for STI transmission, acquisition, and clinical manifestation may prove to be an important strategy in our efforts to curb morbidity in at risk populations.
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Affiliation(s)
- Andreea Waltmann
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cynthia Thomas
- Graduate Program, Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Joseph A Duncan
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Pharmacology, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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3
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Kissinger PJ, Gaydos CA, Seña AC, Scott McClelland R, Soper D, Secor WE, Legendre D, Workowski KA, Muzny CA. Diagnosis and Management of Trichomonas vaginalis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines. Clin Infect Dis 2022; 74:S152-S161. [PMID: 35416973 PMCID: PMC9006969 DOI: 10.1093/cid/ciac030] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Trichomonas vaginalis is likely the most prevalent nonviral sexually transmitted infection, affecting an estimated 3.7 million women and men in the United States. Health disparities are prominent in the epidemiology of trichomoniasis, as African Americans are >4 times more likely to be infected than persons of other races. Since publication of the 2015 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines, additional data have bolstered the importance of T. vaginalis infection sequelae in women, including increased risk of human immunodeficiency virus (HIV) acquisition, cervical cancer, preterm birth, and other adverse pregnancy outcomes. Less is known about the clinical significance of infection in men. Newly available diagnostic methods, including point-of-care assays and multiple nucleic acid amplification tests, can be performed on a variety of genital specimens in women and men, including urine, allowing more accurate and convenient testing and screening of those at risk for infection. Repeat and persistent infections are common in women; thus, rescreening at 3 months after treatment is recommended. In vitro antibiotic resistance to 5-nitroimidazole in T. vaginalis remains low (4.3%) but should be monitored. High rates of T. vaginalis among sexual partners of infected persons suggest a role for expedited partner treatment. A randomized controlled trial in HIV-uninfected women demonstrated that multidose metronidazole 500 mg twice daily for 7 days reduced the proportion of women with Trichomonas infection at 1 month test of cure compared with women receiving single-dose therapy (2 g). The 2-g single-dose oral metronidazole regimen remains the preferred treatment in men.
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Affiliation(s)
- Patricia J Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Charlotte A Gaydos
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Arlene C Seña
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - R Scott McClelland
- Departments of Medicine, Epidemiology, and Global Health, University of Washington, Seattle, Washington, USA
| | - David Soper
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - W Evan Secor
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Davey Legendre
- Comprehensive Pharmacy Services, Woodstock, Georgia, USA
| | - Kimberly A Workowski
- Division of Sexually Transmitted Diseases Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Christina A Muzny
- Division of Sexually Transmitted Diseases Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
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4
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Seña AC, Goldstein LA, Ramirez G, Parish AJ, McClelland RS. Bacterial Vaginosis and Its Association With Incident Trichomonas vaginalis Infections: A Systematic Review and Meta-Analysis. Sex Transm Dis 2021; 48:e192-e201. [PMID: 34433796 PMCID: PMC8594503 DOI: 10.1097/olq.0000000000001537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bacterial vaginosis (BV) has been associated with an increased risk for acquisition of human immunodeficiency virus and sexually transmitted infections. We evaluated the association between BV and incident Trichomonas vaginalis (TV) infection in women. METHODS MEDLINE and ClinicalTrials.gov were searched for articles published between January 1, 1980, and May 7, 2021. Observational studies in women that evaluated the relationship between having/not having BV and the risk for acquiring TV were included. RESULTS Fourteen studies were included in the systematic review; 12 studies were included in meta-analyses involving 18,424 participants. Most studies used Nugent scoring to diagnose BV. For TV diagnosis, 12 studies used wet mount microscopy or culture, and 2 used nucleic acid amplification tests. There was diversity in the measures of association used, so an overall effect size could not be calculated. The majority of studies reported odds ratios, which showed an increased risk of incident TV among women with BV versus without BV (adjusted odds ratio, 1.87; 95% confidence interval, 1.45-2.40; P = 0.007). However, there were heterogeneity and potential confounding factors (eg, age, sexual partners) reported among studies. CONCLUSIONS This systematic review and meta-analysis provide evidence for a nearly 2-fold higher risk for acquiring TV among women with BV compared with women without BV.
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Affiliation(s)
- Arlene C. Seña
- From the Department of Medicine, University of North Carolina Institute for Global Health and Infectious Diseases, Chapel Hill, NC
| | | | - Gilbert Ramirez
- School of Public Health, Texas A&M University, College Station, TX
| | - Austin J. Parish
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, NY
| | - R. Scott McClelland
- Departments of Medicine, Epidemiology and Global Health, University of Washington, Seattle, WA
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5
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 767] [Impact Index Per Article: 255.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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6
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Diagnosis, Treatment, Follow-up, and Persistence of Trichomonas vaginalis in Women 45 Years and Older According to HIV Status: A 10-Year Retrospective Cohort. Sex Transm Dis 2021; 47:332-337. [PMID: 32149959 DOI: 10.1097/olq.0000000000001159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trichomonas vaginalis is a common treatable sexually transmitted infection among older women. Persistent T. vaginalis infection after treatment is common among women with human immunodeficiency virus (HIV). We sought to determine if HIV-negative women were as likely as women with HIV to have persistent T. vaginalis infection. METHODS We performed a retrospective cohort study of women 45 years or older with T. vaginalis infection. We evaluated differences in persistent T. vaginalis infection according to HIV status using χ analysis. We performed regression analyses to describe factors associated with persistent and recurrent infection in older women. RESULTS Over a 10-year study period, we identified 282 women with T. vaginalis, 46 with HIV. Most women (240, 86%) were treated in accordance with 2015 Centers for Disease Control and Prevention Sexually Transmitted Diseases treatment guidelines. Half of the women (144, 53%) had a repeat T. vaginalis test 90 to 365 days after treatment, and one third had persistent infection (39/125, 31%). Persistent infection was similar between women with HIV and HIV-negative women treated according to Centers for Disease Control recommendations (17% vs 33%, P = 0.3). When adjusting for age and incidental diagnosis, tobacco use was associated with an increased risk of more than 1 or recurrent T. vaginalis infection during the study period (adjusted odds ratio, 2.8; 95% confidence interval, 1.5-4.9). CONCLUSIONS The HIV status did not affect persistent T. vaginalis infection in women 45 years or older. Given over one third of women have a positive test within a year after the recommended treatment, our data support repeat testing in women 45 years and older treated for T. vaginalis.
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7
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OuYang Z, Wu J, Xu Y, Wei S, Zhong B, Zhang M, Li F. Single-dose versus multidose metronidazole for the treatment of vaginal trichomoniasis: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 255:56-62. [PMID: 33080486 DOI: 10.1016/j.ejogrb.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this meta-analysis is to further explore the effectiveness of multidose metronidazole (MTZ) and single-dose MTZ in the treatment of trichomoniasis. STUDY DESIGN Search all the literature on MTZ for trichomoniasis in the Pubmed, Ovid Embase, Ovid MEDLIN and Cochrane Library databases. The search period is from the establishment of the database to September 10, 2020. Two authors independently screened the literatures based on inclusion and exclusion criteria, and independent extraction and integration of literature data. The main observation indicators were treatment failure rate and side-effects. Data analysis was performed using RevMan5.2 software. The risk ratio (RR) and 95 % confidence interval (CI) were used as the effect scale indicators of the counting data. P < 0.05 was considered to be statistically significant. RESULTS A total of 2114 articles were retrieved. After screening, a total of 7 articles were included, including 5 randomized controlled trial (RCT) studies and 2 case-control studies. 745 cases were treated with single-dose MTZ, and 732 cases were treated with multidose MTZ. The single-dose MTZ had a higher failure rate for trichomoniasis than the multidose MTZ, and the difference was statistically significant (RR = 1.07, 95 %CI, 1.03-1.11, P = 0.0003). When a HIV-positive study was excluded, the failure rate of the single-dose MTZ was still significantly higher than that of the multidose MTZ (RR = 1.62, 95 %CI, 1.19-2.22, P = 0.002). The side-effects of the single-dose MTZ were higher than those of the multidose MTZ, but the difference was not statistically significant (RR = 1.06, 95 %CI, 0.88-1.27, P = 0.53). CONCLUSION Although based on available data, multidose MTZ is more effective than single-dose MTZ for trichomoniasis, this advantage is not as obvious as previously proven. This small advantage may be lower if considering the compliance of multidose MTZ in the real world. Therefore, more high-quality studies are needed to confirm this before suggesting a multidose MTZ as the first line treatment for HIV-negative trichomoniasis.
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Affiliation(s)
- Zhenbo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Jiawen Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yujing Xu
- Department of Obstetrics, Weifang People's Hospital, Weifang, China
| | - Shiyuan Wei
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Biting Zhong
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Min Zhang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Feng Li
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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8
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Medina-Marino A, Mudau M, Kojima N, Peters RP, Feucht UD, Vos LD, Olivier D, Muzny CA, McIntyre JA, Klausner JD. Persistent Chlamydia trachomatis, Neisseria gonorrhoeae or Trichomonas vaginalis positivity after treatment among human immunodeficiency virus-infected pregnant women, South Africa. Int J STD AIDS 2020; 31:294-302. [PMID: 32089090 PMCID: PMC7174825 DOI: 10.1177/0956462419898612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The objective of this study is to assess the predictors and frequency of persistent sexually transmitted infection (STI) positivity in human immunodeficiency virus (HIV)-infected pregnant women treated for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) or Trichomonas vaginalis (TV) infection. We enrolled HIV-infected pregnant women attending their first antenatal care visit and tested them for urogenital CT, NG and TV infection using Xpert® CT/NG and TV assays (Cepheid, Sunnyvale, CA). Those testing positive were treated. Participants either notified partners to seek treatment or were given extra medication to deliver to partners for treatment. Repeat testing was conducted approximately 21 days post-treatment or treatment initiation. Among 427 participants, 172 (40.3%) tested positive for any STI. Of the 136 (79.1%) that returned for repeat testing, 36 (26.5%) tested positive for the same organism: CT = 27 (26.5%), NG = 1 (6.3%), TV = 11 (16.7%). Persistent CT positivity was independently associated with having more than one sex partner in the preceding 12 months (adjusted-prevalence ratio [aPR] = 3.03, 95% CI: 1.44–6.37) and being newly diagnosed with HIV infection during the first antenatal care visit compared to those currently on antiretroviral therapy (aPR = 3.97, 95% CI: 1.09–14.43). Persistent TV positivity was associated with not knowing if a partner sought treatment following STI disclosure (aPR = 12.6, 95% CI: 2.16–73.5) and prior diagnosis of HIV but not currently on antiretroviral therapy. (aPR = 4.14; 95% CI: 1.25–13.79). We identified a high proportion of HIV-infected pregnant women with persistent CT or TV positivity after treatment. To decrease the risk of re-infection, enhanced strategies for partner treatment programmes are needed to improve the effectiveness of STI screening and treatment in pregnancy. The relationship between not being on antiretroviral therapy and persistent STI positivity needs further study.
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Affiliation(s)
- Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa.,The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Maanda Mudau
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Noah Kojima
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Remco Ph Peters
- Anova Health Institute, Johannesburg, South Africa.,Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Department of Medical Microbiology, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ute D Feucht
- Department of Health, Tshwane District, Gauteng, South Africa.,Department of Pediatrics, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, South African Medical Research Council, Pretoria, South Africa
| | - Lindsey De Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Dawie Olivier
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jeffrey D Klausner
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.,Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
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9
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Unexpected High Rates of Persistent Trichomonas vaginalis Infection in a Retrospective Cohort of Treated Pregnant Women. Sex Transm Dis 2019; 46:2-8. [DOI: 10.1097/olq.0000000000000902] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Muzny CA, Tamhane AR, Eaton EF, Hudak K, Burkholder GA, Schwebke JR. Incidence and predictors of reinfection with trichomoniasis based on nucleic acid amplification testing results in HIV-infected patients. Int J STD AIDS 2018; 30:344-352. [PMID: 30486764 DOI: 10.1177/0956462418807115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Trichomonas vaginalis infection contributes to HIV transmission. The study objective was to determine the incidence and predictors of T. vaginalis reinfection among HIV-infected women in Birmingham, Alabama. A retrospective cohort study of women at an urban HIV clinic from August 2014 to March 2016 with T. vaginalis by nucleic acid amplification test (NAAT) was conducted. Time to first episode of reinfection was evaluated using Kaplan-Meier survival curves. The association of various predictors was evaluated by univariate and multivariable Cox proportional hazards analyses. Of 612 HIV-infected women at the UAB HIV clinic tested for T. vaginalis by the Aptima TV assay, 110 (18.0%) were identified with prevalent T. vaginalis infection. Overall, 25/110 (22.7%) had a first episode of T. vaginalis reinfection by NAAT with a rate of 3.7 reinfections per 100 person-months (95% confidence interval [CI]: 2.3, 5.2). In univariate analysis, only an HIV viral load (VL) ≥200 copies/ml approached statistical significance (hazard ratio = 2.26; 95% CI: 0.97, 5.29, p = 0.06). After adjusting for age and race, the association of HIV VL ≥200 copies/ml remained strong (adjusted hazard ratio = 2.49; 95% CI: 0.99, 6.27, p = 0.05). T. vaginalis reinfection was high among HIV-infected women in this sample, necessitating enhanced disease control efforts in this high-risk population.
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Affiliation(s)
- Christina A Muzny
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashutosh R Tamhane
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ellen F Eaton
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn Hudak
- 2 University of Alabama School of Medicine, Birmingham, AL, USA
| | - Greer A Burkholder
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jane R Schwebke
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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11
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Bradshaw CS, Sobel JD. Current Treatment of Bacterial Vaginosis-Limitations and Need for Innovation. J Infect Dis 2017; 214 Suppl 1:S14-20. [PMID: 27449869 DOI: 10.1093/infdis/jiw159] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Practitioners and patients alike widely recognize the limitations of current therapeutic approaches to the treatment of bacterial vaginosis (BV). Options remain extremely limited, and our inability to prevent the frequently, often relentless symptomatic recurrences of BV and to reduce serious sequelae such as preterm delivery, remains an acknowledged but unresolved shortcoming. Our incomplete understanding of the pathophysiology of this unique form of vaginal dysbiosis has been a significant impediment to developing optimal treatment and prevention approaches. New drugs have not been forthcoming and are not likely to be available in the immediate future; hence, reliance on the optimal use of available agents has become essential as improvised often unproven regimens are implemented. In this review, we will explore the limitations of currently recommended therapies, with a particular focus on the contribution of reinfection and pathogen persistence to BV recurrence, and the development of interventions that target these mechanisms. Ultimately, to achieve sustained cure and effectiveness against BV-associated sequelae, it is possible that we will need approaches that combine antimicrobials with biofilm-disrupting agents and partner treatments in those at risk of reinfection.
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Affiliation(s)
- Catriona S Bradshaw
- Melbourne Sexual Health Centre Central Clinical School, Monash University, Clayton, Australia
| | - Jack D Sobel
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
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12
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Meites E, Gaydos CA, Hobbs MM, Kissinger P, Nyirjesy P, Schwebke JR, Secor WE, Sobel JD, Workowski KA. A Review of Evidence-Based Care of Symptomatic Trichomoniasis and Asymptomatic Trichomonas vaginalis Infections. Clin Infect Dis 2016; 61 Suppl 8:S837-48. [PMID: 26602621 DOI: 10.1093/cid/civ738] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Trichomonas vaginalis is the most prevalent nonviral sexually transmitted infection, affecting an estimated 3.7 million women and men in the United States. Health disparities are prominent in the epidemiology of this infection, which affects 11% of women aged ≥40 years and a disproportionately high percentage of black women. Particularly high prevalences have been identified among sexually transmitted disease (STD) clinic patients and incarcerated individuals. This article reviews and updates scientific evidence in key topic areas used for the development of the 2015 STD Treatment Guidelines published by the Centers for Disease Control and Prevention. Current evidence is presented regarding conditions associated with Trichomonas vaginalis infection, including human immunodeficiency virus (HIV) and pregnancy complications such as preterm birth. Nucleic acid amplification tests and point-of-care tests are newly available diagnostic methods that can be conducted on a variety of specimens, potentially allowing highly sensitive testing and screening of both women and men at risk for infection. Usually, trichomoniasis can be cured with single-dose therapy of an appropriate nitroimidazole antibiotic, but women who are also infected with HIV should receive therapy for 7 days. Antimicrobial resistance is an emerging concern.
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Affiliation(s)
- Elissa Meites
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Charlotte A Gaydos
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marcia M Hobbs
- Departments of Medicine and Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill
| | - Patricia Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Paul Nyirjesy
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane R Schwebke
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham School of Medicine
| | - W Evan Secor
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jack D Sobel
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan
| | - Kimberly A Workowski
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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13
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Kissinger P. Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. BMC Infect Dis 2015; 15:307. [PMID: 26242185 PMCID: PMC4525749 DOI: 10.1186/s12879-015-1055-0] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/22/2015] [Indexed: 12/28/2022] Open
Abstract
Trichomonas vaginalis (TV) is likely the most common non-viral sexually transmitted infection (STI) in the world. It is as an important source of reproductive morbidity, a facilitator of HIV transmission and acquisition, and thus it is an important public health problem. Despite its importance in human reproductive health and HIV transmission, it is not a reportable disease and surveillance is not generally done. This is problematic since most persons infected with TV are asymptomatic. Metronidazole (MTZ) has been the treatment of choice for women for decades, and single dose has been considered the first line of therapy. However, high rates of retest positive are found among TV infected persons after single dose MTZ treatment. This has not been explained by drug resistance since in vitro resistance is only 2-5 %. Treatment failure can range from 7-10 % and even higher among HIV+ women. Treatment efficacy may be influenced by vaginal ecology. The origins of repeat positives need further explanation and better treatment options are needed.
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Affiliation(s)
- Patricia Kissinger
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street Suite 2004, New Orleans, Louisiana, 70112, USA.
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Alcaide ML, Feaster DJ, Duan R, Cohen S, Diaz C, Castro JG, Golden MR, Henn S, Colfax GN, Metsch LR. The incidence of Trichomonas vaginalis infection in women attending nine sexually transmitted diseases clinics in the USA. Sex Transm Infect 2015; 92:58-62. [PMID: 26071390 DOI: 10.1136/sextrans-2015-052010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/25/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Trichomoniasis (TV) is associated with an increased risk of acquisition of sexually transmitted diseases (STDs) and HIV. The purpose of this study is to evaluate factors associated with incidence TV among female STD clinic attendees in the USA. METHODS Data were collected from women participating in a randomised controlled trial evaluating brief risk reduction counselling at the time of HIV testing to reduce sexually transmitted infections (STIs) incidence in STD clinics. Participants recruited from STD clinics underwent STI testing at baseline and 6-month follow-up. TV testing was performed using Nucleic Acid Amplification Test. RESULTS 1704 participants completed study assessments. Prevalence of TV was 14.6%, chlamydia 8.6%, gonorrhoea 3.0%, herpes simplex virus 2 44.7% and HIV 0.4%. Cumulative 6-month incidence of TV was 7.5%. Almost 50% of the incident TV cases had TV at baseline and had received treatment. Factors associated with incidence of TV were having chlamydia, TV and HIV at baseline: TV relative risk (RR)=3.37 (95% CI 2.35 to 4.83, p<0.001); chlamydia RR=1.92 (95% CI 1.23 to 2.99, p=0.04); and HIV=1.59 (95% CI 1.01 to 2.50, p=0.047). CONCLUSIONS Prevalent and incident TV is common among STD clinic attendees; and baseline TV is the main risk factor for incident TV, suggesting high rates of reinfection or treatment failures. This supports the importance of rescreening women after treatment for TV, evaluating current treatment regimens and programmes to ensure treatment of sexual partners. CLINICAL TRIAL NUMBER NCT01154296.
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Affiliation(s)
- Maria L Alcaide
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rui Duan
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie Cohen
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Chanelle Diaz
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jose G Castro
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Sarah Henn
- Whitman-Walker Health, Washington DC, USA
| | - Grant N Colfax
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
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15
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Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1-137. [PMID: 26042815 PMCID: PMC5885289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.
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Affiliation(s)
- Kimberly A. Workowski
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
- Emory University, Atlanta, Georgia
| | - Gail A. Bolan
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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Abstract
Trichomonas vaginalis is the most common nonviral sexually transmitted infection (STI) in the world. It was once thought to be a nuisance STI, but it is now being recognized as an important source of reproductive morbidity and a facilitator of HIV transmission and acquisition, and thus it is an important public health problem. The prevalence of T. vaginalis varies greatly by geography and risk group, but is more common among persons of African descent and appears to increase with age, though this may be a screening phenomenon. Wet mount and culture are simple diagnostics, but have lower sensitivity than nucleic acid amplification techniques presently approved for women only. Single dose (2 g) metronidazole (MTZ) for both the index patient and their sexual partners is the preferred treatment. High rates of retest positivity are found after single-dose treatment which are likely due to clinical resistance rather than re-infection and/or drug resistance.
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Affiliation(s)
- Patricia Kissinger
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street SL-18, New Orleans, LA, 70112, USA,
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Medley A, Bachanas P, Grillo M, Hasen N, Amanyeiwe U. Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence. J Acquir Immune Defic Syndr 2015; 68 Suppl 3:S286-96. [PMID: 25768868 PMCID: PMC4666299 DOI: 10.1097/qai.0000000000000520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs). METHODS We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used. RESULTS Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions. CONCLUSIONS This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.
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Affiliation(s)
- Amy Medley
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Pamela Bachanas
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Michael Grillo
- Naval Health Research Center, Department of Defense, HIV/AIDS Prevention Program, San Diego, CA
| | - Nina Hasen
- U.S. Department of State, Office of the US Global AIDS Coordinator and Health Diplomacy, Washington, DC
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Co-occurrence of Trichomonas vaginalis and bacterial vaginosis and vaginal shedding of HIV-1 RNA. Sex Transm Dis 2014; 41:173-9. [PMID: 24521723 DOI: 10.1097/olq.0000000000000089] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trichomonas vaginalis (TV) and bacterial vaginosis (BV) are independently associated with increased risk of vaginal shedding in HIV-positive women. Because these 2 conditions commonly co-occur, this study was undertaken to examine the association between TV/BV co-occurrence and vaginal shedding of HIV-1 RNA. METHODS HIV-positive women attending outpatient HIV clinics in 3 urban US cities underwent a clinical examination; were screened for TV, BV, Neisseria gonorrhoeae, Chlamydia trachomatis, and vulvovaginal candidiasis; and completed a behavioral survey. Women shedding HIV-1 RNA vaginally (≥50 copies/mL) were compared with women who had an undetectable (<50 copies/mL) vaginal viral load to determine if women who were TV positive and BV positive or had co-occurrence of TV/BV had higher odds of shedding vaginally when compared with women who did not have these conditions. RESULTS In this sample of 373 HIV-positive women, 43.1% (n = 161) had co-occurrence of TV/BV and 33.2% (n = 124) were shedding HIV-1 RNA vaginally. The odds of shedding HIV vaginally in the presence of TV alone or BV alone and when TV/BV co-occurred were 4.07 (95% confidence interval [CI], 1.78-9.37), 5.65 (95% CI, 2.64-12.01), and 18.63 (95% CI, 6.71-51.72), respectively, when compared with women with no diagnosis of TV or BV, and after adjusting for age, antiretroviral therapy status, and plasma viral load. CONCLUSIONS T. vaginalis and BV were independently and synergistically related to vaginal shedding of HIV-1 RNA. Screening and prompt treatment of these 2 conditions among HIV-positive women are important not only clinically but for HIV prevention, as well.
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Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis. PLoS One 2014; 9:e105645. [PMID: 25265158 PMCID: PMC4179256 DOI: 10.1371/journal.pone.0105645] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/16/2014] [Indexed: 11/19/2022] Open
Abstract
Purpose We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally. Methods We systematically searched PubMed, Embase and MEDLINE in March 2014 to identify studies reporting on ART uptake, attrition, adherence, and outcomes (viral suppression or CD4 count improvements) among HIV-infected FSWs globally. When possible, available estimates were pooled using random effects meta-analyses (with heterogeneity assessed using Cochran's Q test and I2 statistic). Results 39 studies, reporting on 21 different FSW study populations in Asia, Africa, North America, South America, and Central America and the Caribbean, were included. Current ART use among HIV-infected FSWs was 38% (95% CI: 29%–48%, I2 = 96%, 15 studies), and estimates were similar between high-, and low- and middle-income countries. Ever ART use among HIV-infected FSWs was greater in high-income countries (80%; 95% CI: 48%–94%, I2 = 70%, 2 studies) compared to low- and middle-income countries (36%; 95% CI: 7%–81%, I2 = 99%, 3 studies). Loss to follow-up after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies) and death after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies). The fraction adherent to ≥95% of prescribed pills was 76% (95% CI: 68%–83%, I2 = 36%, 4 studies), and 57% (95% CI: 46%–68%, I2 = 82%, 4 studies) of FSWs on ART were virally suppressed. Median gains in CD4 count after 6 to 36 months on ART, ranged between 103 and 241 cells/mm3 (4 studies). Conclusions Despite global increases in ART coverage, there is a concerning lack of published data on HIV treatment for FSWs. Available data suggest that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings. More routine programme data on HIV treatment among FSWs across settings should be collected and disseminated.
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Mountain E, Pickles M, Mishra S, Vickerman P, Alary M, Boily MC. The HIV care cascade and antiretroviral therapy in female sex workers: implications for HIV prevention. Expert Rev Anti Infect Ther 2014; 12:1203-19. [PMID: 25174997 DOI: 10.1586/14787210.2014.948422] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
To achieve viral suppression and fully benefit from antiretroviral therapy (ART), it is important that individuals with HIV know that they are HIV infected, link to and remain in HIV care, start and remain on ART and adhere to treatment. In HIV epidemics where female sex workers (FSWs) are key drivers of HIV transmission, the extent to which FSWs use ART and engage in the HIV care cascade could have a considerable impact on HIV transmission from FSWs to the wider population. In this article we review the spectrum of FSW engagement in the HIV care cascade, look at the impact of the HIV care cascade and ART use among FSWs on population-level HIV transmission and discuss HIV prevention for FSWs in the context of ART and the HIV care cascade.
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Affiliation(s)
- Elisa Mountain
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Adamski A, Clark RA, Mena L, Henderson H, Levison J, Schmidt N, Gebrekristos HT, Martin DH, Kissinger P. The influence of ART on the treatment of Trichomonas vaginalis among HIV-infected women. Clin Infect Dis 2014; 59:883-7. [PMID: 24917661 DOI: 10.1093/cid/ciu401] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Alys Adamski
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Rebecca A Clark
- Department of Medicine, Louisiana State University, New Orleans
| | - Leandro Mena
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Harold Henderson
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | | | - Norine Schmidt
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Hirut T Gebrekristos
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - David H Martin
- Department of Medicine, Louisiana State University, New Orleans
| | - Patricia Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
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Seña AC, Bachmann LH, Hobbs MM. Persistent and recurrentTrichomonas vaginalisinfections: epidemiology, treatment and management considerations. Expert Rev Anti Infect Ther 2014; 12:673-85. [DOI: 10.1586/14787210.2014.887440] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Does Antiretroviral Therapy Interfere With the Treatment of Trichomonas vaginalis Among HIV+ Women? Sex Transm Dis 2013; 40:506-7. [PMID: 23677024 DOI: 10.1097/olq.0b013e31829335fe] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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