Ann Duerr

Prevalence, Incidence, and Type-Specific Persistence of Human Papillomavirus in Human Immunodeficiency Virus (HIV)-Positive and HIV-Negative Women

Human immunodeficiency virus (HIV) infection and related immunosuppression are associated with excess risk for cervical neoplasia and human papillomavirus (HPV) persistence. Type-specific HPV infection was assessed at 6-month intervals for HIV-positive and HIV-negative women (median follow-up, 2.5 and 2.9 years, respectively). The type-specific incidence of HPV infection was determined, and risk factors for HPV persistence were investigated by statistical methods that accounted for repeated measurements. HIV-positive women were 1.8, 2.1, and 2.7 times more likely to have high-, intermediate-, and low-risk HPV infections, respectively, compared with HIV-negative women. In multivariate analysis, high viral signal, but not viral risk category, was independently associated with persistence among HIV-positive subjects (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.1-2.9). Furthermore, persistence was 1.9 (95% CI, 1.5-2.3) times greater if the subject had a CD4 cell count <200 cells/microL (vs. >500 cells/microL). Thus, HIV infection and immunosuppression play an important role in modulating the natural history of HPV infection.

Bacterial vaginosis and HIV seroprevalence among female commercial sex workers in Chiang Mai, Thailand

ObjectiveTo investigate the relationship between HIV seropositivity and bacterial vaginosis (BV) in a population at high risk for sexual acquisition of HIV. DesignA cross-sectional study was conducted among 144 female commercial sex workers in Chiang Mai, Thailand. MethodsThe participants were tested for cervical gonorrhea and Chlamydia infection, syphilis, Trichomonas vaginitis, Candida vaginitis, BV, and HIV infection. BV was diagnosed by clinical criteria (pH>4.5, positive amine test, and presence of clue cells) and using Gram stains. ResultsThirty-three per cent of participants had BV, and 43% were HIV-positive. Using clinical criteria, the association of BV and HIV seropositivity was significant (odds ratio (OR), 2.7; 95% confidence interval (CD, 1.3–5.0]. Although the association between BV and HIV prevalence was not significant using Gram stains alone for diagnosis of BV, an association was found between abnormal vaginal flora and HIV (OR, 2.1; 95% Cl, 1.0–4.8). In multiple logistic regression analysis, adjusting for age, number of sexual encounters per week, current condom use, and currently having a sexually transmitted disease (STD), both BV and a history of an STD were independently associated with HIV seropositivity (adjusted OR for BV, 4.0 and 95% Cl, 1.7–9.4; adjusted OR for history of an STD, 6.9 and 95% Cl, 2.1–22.9). Conclusions: When diagnosed clinically, BV is independently associated with HIV seroprevalence. HIV infection may promote abnormal vaginal flora, or BV may increase susceptibility to sexual transmission of HIV. Alternatively, the association seen here may result from intervening variables; in this case BV may be a marker or a cofactor of HIV transmission.

male Viral Load and Heterosexual Transmission of Hiv-1 Subtype E in Northern Thailand

&NA; We evaluated the association between HIV‐1 RNA copies/mL in men and heterosexual transmission to their female partners among 493 couples in Thailand. Husbands were identified as HIV‐positive when they were screened as blood donors; nearly all were infected with HIV subtype E. Wives had no known risks for HIV infection other than sex with their husbands. In multivariate analysis, each log10 increment of HIV RNA in the man was associated with an 81% increased rate of HIV transmission to his wife (odds ratio = 1.81, 95% confidence interval: 1.33‐2.48). No transmission occurred at viral loads below 1094 copies/mL, and a dose‐response effect was seen with increasing viral load in the man. In multivariate analysis, a history of a sexually transmitted disease in the man or woman, longer duration of hormonal contraceptive use, and the womans onset of sexual activity at less than 20 years of age were also associated with increased seropositivity of the wife.

Longitudinal Study of Cervical Squamous Intraepithelial Lesions in Human Immunodeficiency Virus (HIV)-Seropositive and At-Risk HIV-Seronegative Women

We examined incidence and correlates of progression and regression of abnormal cervical cytologic test results, defined as at least low-grade squamous intraepithelial lesions (SILs), in 774 human immunodeficiency virus (HIV)-seropositive and 391 HIV-seronegative women monitored semiannually for up to 5.5 years. During follow-up, 224 (35%) HIV-seropositive women and 34 (9%) HIV-seronegative women had incident SILs detected by Pap test; 47 (7%) HIV-seropositive women developed high-grade lesions. The incidence of SILs was 11.5 cases among HIV-seropositive and 2.6 cases among HIV-seronegative women per 100 person-years of observation (rate ratio, 4.5; 95% confidence interval, 3.1-6.4; P<.001). Risk of incident SILs and likelihood of Pap test progression were increased among HIV-seropositive women with CD4(+) lymphocyte counts <500 cells/mm(3) and among women with human papillomavirus (HPV) infection, with risk-ordering from low- to high-risk HPV type. SIL regression was less likely among HIV-seropositive women with higher HIV loads. No beneficial effect of highly active antiretroviral therapy was demonstrated.

Complications of interval laparoscopic tubal sterilization: findings from the United States collaborative review of sterilization☆

Objective To estimate the risk of intraoperative or postoperative complications for interval laparoscopic tubal sterilizations. Methods We used a prospective, multicenter cohort study of 9475 women who had interval laparoscopic tubal sterilization to calculate the rates of intraoperative or postoperative complications. The relative safety of various methods was assessed by calculating overall complication rates for each major method of tubal occlusion. Method-related complication rates also were calculated and included only complications attributable to a method of occlusion. We used logistic regression to identify independent predictors of one or more complications. Results When we used a more restrictive definition of unintended major surgery, the overall rate of complications went from 1.6 to 0.9 per 100 procedures. There was one life-threatening event and there were no deaths. Complications rates for each of the four major methods of tubal occlusion ranged from 1.17 to 1.95, with no significant differences between them. When complication rates were calculated, the spring clip method had the lowest method-related complication rate (0.47 per 100 procedures), although it was not significantly different from the others. In adjusted analysis, diabetes mellitus (adjusted odds ratio [OR] 4.5; 95% confidence interval [CI] 2.3, 8.8), general anesthesia (OR 3.2; CI 1.6, 6.6), previous abdominal or pelvic surgery (OR 2.0; CI 1.4, 2.9), and obesity (OR 1.7; CI 1.2, 2.6) were independent predictors of one or more complications. Conclusion Interval laparoscopic sterilization generally is a safe procedure; serious morbidity is rare.

Violence Among Women with or at Risk for HIV Infection

To estimate the prevalence and to identify correlates of physical and sexual assaults or abuse among women with or at risk for HIV infection, a cross-sectional survey was conducted within a longitudinal cohort study. A total of 765 HIV-seropositive and 367 HIV-seronegative women with a history of injection drug use (51%) or high-risk sex (49%) completed the interview. Both physical abuse and sexual abuse as a child were common for both HIV-seropositive (41.3%, 41.0%) and uninfected women (43.3%, 45.8%), respectively. Both physical abuse and sexual abuse as adults were even more common in both HIV-seropositive (66.4%, 45.7%) and HIV-seronegative women (69.2%, 48.8%), respectively. In the 6 months prior to interview, the most important predictors for being the victim of violence was age <30 years old, use of crack, use of marijuana, having multiple sex partners, and not having a steady sex partner. However, even after accounting for these other factors, HIV-infected women with low CD4 cell counts (<350/μl) were less likely than the other women to experience recent violence. While the lower rate of recent violence among those with low CD4 cell count probably represents effects of HIV-related disability, women at high risk for HIV remain at high risk for violence. Both HIV prevention and treatment services need to recognize the background level of violence and incorporate appropriate counseling services.

Longitudinal analysis of bacterial vaginosis: Findings from the HIV epidemiology research study

OBJECTIVE To determine the natural history of bacterial vaginosis in women with or at risk for human immunodeficiency virus (HIV). METHODS A cohort of 854 HIV‐infected women and 434 HIV‐uninfected women from four US sites was followed prospectively with gynecologic exams every 6 months over a 5‐year period. The prevalence, incidence, persistence, and severity of bacterial vaginosis, which was defined using a Gram‐staining scoring system, were calculated using generalized estimating equation methods. RESULTS In adjusted analyses, HIV‐infected women had a higher prevalence of bacterial vaginosis than HIV‐uninfected women (adjusted odds ratio [OR] 1.29; 95% confidence interval [CI] 1.08, 1.55). Although HIV‐infected women were not more likely to have incident infections, they were more likely to have persistence of their infections (adjusted OR 1.49; 95% CI 1.18, 1.89). Similarly, immunocompromised women (CD4+ cell count less than 200 cells/μL) were more likely than HIV‐infected women with higher CD4+ cell counts (more than 500 cells/μL) to have prevalent (adjusted OR 1.29; 95% CI 1.03, 1.60) and persistent (adjusted OR 1.38; 95% CI 1.01, 1.91) bacterial vaginosis infections, but not more likely to have incident infections. Immunocompromised women had more severe bacterial vaginosis by both clinical criteria (adjusted OR 1.40; 95% CI 1.08, 1.82) and by Gram‐staining criteria (adjusted OR 1.50; 95% CI 1.12, 2.00). CONCLUSIONS Bacterial vaginosis is more prevalent and persistent among HIV‐infected women, particularly among those who are immunocompromised. Immunocompromised women are more likely than HIV‐infected women with higher CD4+ cell counts to have severe bacterial vaginosis.

Breast milk and HIV-1: vector of transmission or vehicle of protection?

Transmission of HIV-1 to the infant through breastfeeding is a major cause of new paediatric HIV-1 infections worldwide. Although extended breastfeeding accounts for approximately 40% of infant HIV infections worldwide, most breastfed infants remain uninfected, despite prolonged and repeated exposure to HIV-1. Mechanisms associated with transmission of HIV-1 through breastfeeding and factors related to protection from such transmission remain poorly understood. Here we focus on the cellular origin of HIV in breast milk and on immune factors within the milk that may offer protection from transmission of HIV infection. The presence of innate immunity and induction of adaptive immunity against HIV is explored: in particular, specific antibodies, cellular responses, and their significance. The role of mucosal immune activation and epithelial integrity in HIV transmission is also addressed. We are of the opinion that advances in laboratory methods that study specific aspects of immunity will help open new areas of understanding of HIV transmission through breastfeeding and mechanisms of protection, and contribute to the development of novel prevention strategies.

Longitudinal Study of Mucosal Candida Species Colonization and Candidiasis among Human Immunodeficiency Virus (HIV)-Seropositive and At-Risk HIV-Seronegative Women

Acquisition and loss rates and estimates of duration of oral and vaginal Candida species colonization and candidiasis were examined among 868 human immunodeficiency virus (HIV)-seropositive and 437 at-risk HIV-seronegative women monitored prospectively during 1993-1999. Colonization and candidiasis acquisition rates, both oral and vaginal, were significantly higher among HIV-seropositive women; the magnitude of increase in candidiasis outcomes for HIV-seropositive women was greater for oral candidiasis than for vaginal candidiasis. Loss rates and estimates of duration of incident outcomes indicated that persistent mucosal colonization was more likely among HIV-seropositive women. However, results did not suggest persistent mucosal candidiasis. Higher HIV loads were significantly associated with increased odds of incident or persistent oral and vaginal colonization and candidiasis, an effect significantly reduced by highly active antiretroviral therapy for the incident outcomes of oral candidiasis and vaginal colonization. Cell-mediated immunodeficiency (CD4(+) lymphocyte count <500 cells/mm(3)) was significantly associated with increased odds of oral colonization or candidiasis, but not with vaginal colonization or candidiasis. In HIV-seropositive women, mucosal candidiasis is the consequence of multiple interacting factors.

The impact of HIV infection and immunodeficiency on human papillomavirus type 6 or 11 infection and on genital warts.

Background HIV infection and associated immunodeficiency are known to alter the course of human papillomavirus (HPV) infections and of associated diseases. Goal This study investigated the association between HIV and HPV and genital warts. Study Design HPV testing and physical examinations were performed in two large prospective studies: the Womens Interagency HIV Study (WIHS) and the HIV Epidemiology Research Study (HERS). Statistical methods incorporating dependencies of longitudinal data were used to examine the relationship between HIV and HPV and genital warts. Results A total of 1008 HIV-seronegative and 2930 HIV-seropositive women were enrolled in the two studies. The prevalence of HPV 6 or 11 was 5.6 times higher in HIV-seropositive women in the WIHS and 3.6 times higher in the HERS. Genital wart prevalence increased by a factor of 3.2 in the WIHS and 2.7 in the HERS in HIV-seropositive women. In the WIHS, infection with HPV type 6 or 11, in comparison with no HPV infection, was associated with odds of genital wart prevalence of 5.1 (95% CI: 2.9–8.8), 8.8 (95% CI: 6.1–12.8), and 12.8 (95% CI: 8.8–18.8) in HIV-seronegative women, HIV-seropositive women with ≥201 CD4 cells/&mgr;l, and HIV-seropositive women with ≤200 CD4 cells/&mgr;l, respectively. In the HERS, infection with HPV type 6 or 11 was associated with odds of 2.7 (95% CI: 1.6–4.6), 4.9 (95% CI: 3.2–7.7), and 5.3 (95% CI: 3.3–8.5) in these same groups. Other HPV types showed a similar dose–response relation, but of substantially lower magnitude and statistical significance. Conclusions HIV infection and immunodeficiency synergistically modified the relation between HPV 6 or 11 infection and genital wart prevalence.