Women view key sexual behaviours as the trigger for the onset and recurrence of bacterial vaginosis

Psychosocial impact of recurrent urogenital infections: a review

Recurrent urogenital infections such as bacterial vaginosis, vulvovaginal candidiasis, and urinary tract infections have a high prevalence and pronounced psychosocial impact. However, no review has compared the psychosocial impacts across infection types. This narrative review discusses the impact of common recurrent urogenital infections on psychosocial aspects, including quality of life, stress, mental health, sexual health, work productivity, race and ethnicity, and satisfaction of medical care. Validated questionnaires show that women with recurrent vulvovaginal candidiasis and urinary tract infections have decreased scores on all aspects of quality of life. Those with recurrent vulvovaginal candidiasis and urinary tract infections show lower mental health scores compared to the general population, with increased risk of anxiety and depression. Recurrent urogenital infections affect sexual relationships and intimacy, including avoidance due to symptoms or as a method of prevention. Recurrent infections also increase medical cost and negatively affect work productivity, leading to a combined estimated cost of over US$13 billion per year. There are clear effects of racial inequality involving minority populations that affect diagnosis, treatment, prevalence, and reporting of recurrent urogenital infections. Satisfactory medical treatment improves quality of life and mental health in those suffering from these conditions. Research evaluating psychosocial aspects of recurrent urogenital infections is variable and is not comparable across vulvovaginal conditions. Even so, psychosocial factors are important in understanding contribution and consequence of urogenital infections. Education, awareness, normalization, community support, and access to care can help to alleviate the negative implications of recurrent urogenital infections.

Lactic acid gel versus metronidazole for recurrent bacterial vaginosis in women aged 16 years and over: the VITA RCT

Background

Bacterial vaginosis is a common and distressing condition associated with serious comorbidities. Antibiotic treatment is usually clinically effective in the short term, but recurrence is common and side effects can occur.

Objectives

The objective is to assess whether or not intravaginal lactic acid gel is clinically effective and cost-effective for treating recurrent bacterial vaginosis compared with oral metronidazole (Flagyl, Sanofi).

Design

This was an open-label, multicentre, parallel-arm, randomised (1 : 1) controlled trial.

Setting

This took place in one general practice and 19 sexual health centres in the UK.

Participants

Women aged ≥ 16 years with bacterial vaginosis symptoms and one or more episode(s) within the past 2 years took part.

Interventions

The interventions were 5 ml of intravaginal lactic acid gel taken once daily for 7 days (intervention) or 400-mg oral metronidazole tablets taken twice daily for 7 days (control).

Main outcome measures

The primary outcome was the resolution of bacterial vaginosis symptoms 14 days after randomisation. The secondary outcomes were time to first recurrence of symptoms; number of recurrences and treatment courses over 6 months; microbiological resolution on microscopy of vaginal smears at week 2; time to resolution of symptoms; tolerability, adherence and acceptability of the treatment; prevalence of concurrent sexually transmitted infections; quality of life; and cost-effectiveness.

Results

Recruitment stopped prior to reaching the target of 1900 participants on recommendation from the Data Monitoring Committee and Trial Steering Committee after a planned review of the results indicated that the research question had been answered. Overall, 518 participants were randomised and primary outcome data were available for 409 participants (79%; 204 in the metronidazole arm, 205 in the lactic acid gel arm). Participant-reported symptom resolution at week 2 was higher with metronidazole (143/204; 70%) than with lactic acid gel (97/205; 47%) (adjusted risk difference –23.2%, 95% confidence interval –32.3% to –14.0%). Recurrence in 6 months in a subset of participants who had initial resolution and were available for follow-up was similar across arms (metronidazole arm: 51/72, 71%; lactic acid gel arm: 32/46, 70%). A higher incidence of some side effects was reported with metronidazole than with lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). At week 2, the average cost per participant with resolved symptoms was £86.94 (metronidazole), compared with £147.00 (lactic acid gel). Some participants preferred using lactic acid gel even if they perceived it to be less effective than metronidazole.

Limitations

Loss to follow-up for collection of the primary outcome data was 21% and was similar in both arms. There is a risk of bias owing to missing outcome data at 3 and 6 months post treatment.

Conclusions

A higher initial response was seen with metronidazole than with lactic acid gel, but subsequent treatment failure was common with both. Lactic acid gel was less cost-effective than metronidazole. In general, women disliked taking repeated courses of metronidazole and preferred lactic acid gel, even when they were aware that it was less likely to provide symptom resolution. In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients. Further microbiological analysis of vaginal samples would be useful to identify additional factors affecting response to treatment.

Trial registration

Current Controlled Trials ISRCTN14161293.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 2. See the NIHR Journals Library website for further project information.

Bacterial Vaginosis and Alcohol Consumption: A Cross-Sectional Retrospective Study in Baltimore, Maryland

BACKGROUND

Bacterial vaginosis (BV) is the most cited cause of vaginal complaints among women of reproductive age. Its etiology and associated risk factors are not entirely understood. Here we examined the association between BV and at-risk alcohol consumption in women attending 2 sexually transmitted infection (STI) clinics in Baltimore, MD.

METHODS

This was a retrospective cross-sectional analysis using data from first clinic visits from 2011-2016. At-risk alcohol use was defined as heavy episodic ("binge") drinking within the last 30 days or a self-report of having had vaginal or anal sex in the context of alcohol consumption. Pearson χ2 test and Student t test were used to assess baseline associations. Log binomial models were used to estimate prevalence ratios (PRs) before and after adjustments for potential confounding factors.

RESULTS

Of the 10,991 women included in the analysis, 2173 (19.7%) met the clinical diagnostic criteria for BV. Having had vaginal or anal sex in the context of alcohol consumption was associated with an increased risk of BV (PR, 1.25; 95% confidence interval, 1.13-1.37), as was binge drinking (PR, 1.15; 95% confidence interval, 1.04-1.27) after adjustment for confounders.

CONCLUSIONS

In this population, at-risk alcohol consumption was associated with an increased risk of BV. The mechanisms remain uncertain. Future prospective studies are needed to verify and evaluate causality in these associations.

Sex Work Is Associated With Increased Vaginal Microbiome Diversity in Young Women From Mombasa, Kenya

BACKGROUND

Although nonoptimal vaginal bacteria and inflammation have been associated with increased HIV risk, the upstream drivers of these phenotypes are poorly defined in young African women.

SETTING

Mombasa, Kenya.

METHODS

We characterized vaginal microbiome and cytokine profiles of sexually active young women aged 14-24 years (n = 168) in 3 study groups: those engaging in formal sex work, in transactional sex, and nonsex workers. Vaginal secretions were collected using self-inserted SoftCup, and assayed for cytokines and vaginal microbiome through multiplex ELISA and 16S rRNA sequencing, respectively. Epidemiological data were captured using a validated questionnaire.

RESULTS

The median age of participants was 20 years (interquartile range: 18-22 years). Approximately two-thirds of young women (105/168) had vaginal microbial communities characterized by Gardnerella and/or Prevotella spp. dominance; a further 29% (49/168) were predominantly Lactobacillus iners. Microbiome clustering explained a large proportion of cytokine variation (>50% by the first 2 principal components). Age was not associated with vaginal microbial profiles in bivariable or multivariable analyses. Women self-identifying as sex workers had increased alpha (intraindividual) diversity, independent of age, recent sexual activity, HIV, and other sexually transmitted infections (beta = 0.47, 95% confidence interval: 0.05 to 0.90, P = 0.03). Recent sex (number of partners or sex acts last week, time since last vaginal sex) correlated with increased alpha diversity, particularly in participants who were not involved in sex work.

CONCLUSION

Nonoptimal vaginal microbiomes were common in young Kenyan women and associated with sex work and recent sexual activity, but independent of age. Restoring optimal vaginal microflora may represent a useful HIV prevention strategy.

Recurrent bacterial vaginosis

ABSTRACT

Bacterial vaginosis increases the risk of sexually transmitted infections, including HIV, and treatment is crucial to avoid complications. This article reviews the evidence-based options for treating bacterial vaginosis to improve patient outcomes.

Recurrent bacterial vaginosis

Bacterial vaginosis recurrence is common but can lead to frequent bothersome symptoms associated with infection. This article reviews evidence-based options for practicing providers to improve patient outcomes. Bacterial vaginosis increases the risk of acquiring sexually transmitted infections, including HIV. Adequate treatment is essential to help avoid adverse patient outcomes.

A review of current guidelines and research on the management of sexually transmitted infections in adolescents and young adults

Adolescents and young adults are at high risk for sexually transmitted infections (STIs). Providers have the responsibility to accurately manage these infections to prevent medical complications and the spread of STIs. This article will review the epidemiology, screening recommendations, diagnostic tests, and treatment guidelines for STIs most commonly encountered in this population: Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus, and Trichomonas vaginalis, as well as the sexually associated infection bacterial vaginosis. This review will discuss ongoing research that explores ways to improve the management of STIs in adolescents and young adults.

Acceptability of and treatment preferences for recurrent bacterial vaginosis-Topical lactic acid gel or oral metronidazole antibiotic: Qualitative findings from the VITA trial

BACKGROUND

Bacterial vaginosis (BV) is associated with an elevated vaginal pH and the presence of abnormal offensive discharge. It is common, often recurrent, and the most effective treatment regimen is unknown. 'Metronidazole Versus lactic acId for Treating bacterial vAginosis' (VITA) is a UK-based randomised controlled trial assessing clinical and cost-effectiveness of topical lactic acid gel compared to oral metronidazole antibiotic for treating second and subsequent BV episodes. Few BV trials report on women's preferences for treatment in the context of their own experiences.

METHOD

This qualitative study investigated the acceptability and tolerability of the two treatments. During the trial, semi-structured telephone interviews were undertaken between January-May 2018. A total of 33 women diagnosed with BV were consecutively sampled then interviewed from six sites across England. Thematic analysis was guided by the acceptability of health interventions framework. Potential causes of BV and its impact on women's lives were explored in addition to women's treatment preference and perceived treatment effectiveness.

RESULTS

Although women felt antibiotics treat BV effectively, and were associated with longer time periods between episodes, they generally preferred using the lactic acid gel because of ease of use, once daily application and less side-effects. Women would recommend the lactic acid gel to others for mild cases of BV but to take antibiotics when more severe. The risk of antibiotic drug resistance was a common concern. Self-help medicating or self-decision to not treat was also evident due to prior experience of poor outcomes from treatment. Triggers of BV were attributed to personal hygiene habits-soaps used to wash the vagina and sexual practices such as unprotected sex.

CONCLUSION

Acceptability and preference for topical lactic acid gel or oral metronidazole tablets in the treatment of recurrent BV was affected by personal choice relating to affective attitude, burden, ethicality, intervention coherence, opportunity costs, and self-efficacy. These differed depending on ease of use, tolerability and past experiences, but not necessarily based on perceived drug effectiveness. Knowledge of a patient preference for topical lactic acid gel therapy despite lower perceived effectiveness may be useful for clinicians when making treatment decisions.

Factors in the HIV risk environment associated with bacterial vaginosis among HIV-negative female sex workers who inject drugs in the Mexico-United States border region

Background

Bacterial vaginosis (BV) is the most common cause of vaginitis among women worldwide and is associated with increased susceptibility to sexually transmitted infections (STIs), including HIV. We aimed to determine the impact of the HIV risk environment on BV among female sex workers who inject drugs (FSW-PWIDs) in Tijuana and Ciudad Juarez, Mexico.

Methods

We performed a cross-sectional analysis utilizing baseline data from a randomized controlled trial evaluating a behavioral HIV prevention intervention. Participants underwent testing for BV using the OSOM BVBlue® Rapid Test (Genzyme Diagnostics, San Diego, CA) and completed a survey eliciting information on the HIV risk environment, sexual risk behaviors, and substance use. We applied logistic regression to identify correlates of BV in the physical, social, economic, and political HIV risk environments stratified by study site (Ciudad Juarez vs. Tijuana).

Results

In total, 584 HIV-negative FSW-PWIDs (300 Ciudad Juarez; 284 Tijuana) were enrolled. The prevalence of BV was 39% (n = 228), which was higher in Ciudad Juarez (56.7%) compared to Tijuana (20.4%). In both cities, micro-level components of the physical HIV risk environment were associated with BV. In Ciudad Juarez, BV was associated with past experiences or threats of physical violence in response to proposed condom use (adjusted odds ratio [aOR] = 3.66, 95% confidence interval [CI]: 1.74–7.69, p = 0.001) and lifetime residence in Ciudad Juarez (aOR = 1.74, 95% CI: 1.05–2.87, p = 0.031). In Tijuana, BV was associated with the number of hours spent on the street daily in the past six months looking for, using, or dealing drugs, engaging in other income generating activities, or sleeping (aOR = 1.05, 95% CI: 1.001–1.097, p = 0.045).

Conclusions

Our findings suggest that FSW-PWIDs’ risk of BV may be shaped by the microphysical HIV risk environment. Addressing components of the physical risk environment, including interventions to reduce gender-based violence, may alleviate the burden of BV and subsequent susceptibility to HIV/STIs among FSW-PWIDs in the Mexico/US border region.

Trial registration

National Institute of Health (NIH) Clinical Trials Identifier NCT00840658, and date of NIH trial registration February 7, 2009.