Anna M. Powell

New Perspectives on the Normal Vagina and Noninfectious Causes of Discharge.

An understanding of how the vaginal flora is influenced by hormonal status is crucial in distinguishing normal from abnormal secretions. New studies exploring the vaginal microbiome with culture-independent techniques have led to the discovery of previously uncultivable bacteria on a species level, and have contributed to a better understanding of disease processes including bacterial vaginosis. It is important to note that not all vaginal discharge is abnormal or infectious in etiology, but a thorough evaluation will help reassure both the patient and the provider.

Increased systemic microbial translocation is associated with depression during early pregnancy

Plasma level of microbial translocation is a marker of mucosal permeability. Increased mucosal permeability ignites elevated microbial translocation and as a consequence of systemic inflammation. Pregnant women with depression have higher levels of inflammatory markers relative to pregnant women without depression, however, no studies have reported whether systemic microbial translocation will change in depressed women during pregnancy. In this study, we examined the plasma LPS level of depressed women during pregnancy. The results showed that the plasma LPS level was significantly increased in depressed mothers during their 8-12 weeks gestation compared to healthy controls. Compared to 8-12 weeks gestation, the plasma LPS levels were significantly decreased at 24-28 weeks gestation and 6-8 weeks postpartum in both depressed subjects and healthy controls. Furthermore, the plasma levels of pro-inflammatory cytokines (TNF-α and MCP/CCL2) associated with microbial translocation were significantly increased in depressed subjects during 8-12 weeks gestation compared to healthy controls. These results indicate that the level of microbial translocation is increased in depressed women during early pregnancy.

The induction of CD80 and apoptosis on B cells and CD40L in CD4+ T cells in response to seasonal influenza vaccination distinguishes responders versus non-responders in healthy controls and aviremic ART-treated HIV-infected individuals

BACKGROUND Studies have shown that HIV infection is associated with an impaired influenza vaccine response. We examined the role of cellular phenotypes and function in influenza vaccine responsiveness in healthy controls and aviremic HIV-infected subjects on antiretroviral treatment (ART). METHODS 16 healthy controls and 26 ART+ aviremic HIV+ subjects were enrolled in the current study. Blood was collected at pre-vaccination (D0), and on days 7-10 (D7) and 14-21 (D14) following the 2013-2014 seasonal influenza vaccine administrations. Subjects were classified as responders if neutralizing titers against H1N1 virus increased ⩾4-fold at D14 compared to D0. A serial analysis of B and CD4+ T cell frequencies and activation was performed on D0 and D7 by flow cytometry. RESULTS 9 of 26 (34.6%) HIV-infected individuals and 7 of 16 (43.8%) healthy controls were classified as responders to influenza vaccines. Total B cell apoptosis (annexin V) was increased on D7 post-vaccination in non-responders but not in responders among both controls and HIV+ subjects. Surface CD80 expression on memory B cells and intracellular CD40L expression on memory CD4+ T cells were induced on D7 in responders of controls but not in non-responders. The CD80 and CD40L induction was not demonstrable in HIV-infected subjects regardless of responders and non-responders. Memory CD4+ T cell cycling tended to increase on D7 in the four study groups but did not achieve significance. All the other parameters were indistinguishable between responders and non-responders, regardless of HIV-infection status. CONCLUSION The perturbation of activation and apoptotic induction on B cells or CD4+ T cells after seasonal influenza vaccination in non-responders and HIV-infected subjects may help understand the mechanism of impaired vaccine responsiveness.

The Effect of HIV-Centered Obstetric Care on Perinatal Outcomes among a Cohort of Women Living with HIV

Background: Elimination of perinatal transmission is possible but limited by missed care opportunities. Our objective was to investigate the effects of HIV-centered obstetric care (HCC) on missed care opportunities and perinatal HIV transmission in 2 obstetric cohorts at our institution from 2000 to 2014. Methods: This was a retrospective cohort study of HIV-exposed mother–infant pairs delivering from 2000 to 2014, analyzed according to SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guidelines. Before 2009, women received care in high-risk obstetric care (HRC); subsequently, an HCC service was established. Women who received HRC vs HCC obstetric care were compared to determine differences in maternal and neonatal outcomes. Continuous variables were compared with Student t test and Wilcoxon rank sum tests. Categorical variables were compared using &khgr;2 test and Fisher exact test. Logistic regression analyses were performed to determine factors associated with outcomes of interest. Results: Over 14 years, 161 women delivered 217 HIV-exposed infants; 78 (36%) women received HCC. Two perinatal HIV transmissions (1.5%) occurred in HRC group compared with none in the HCC group (P = 0.3). Women in HCC were more likely to have HIV RNA viral load <1000 copies per milliliter at delivery (12% vs 26%, P = 0.02), have a contraception plan before delivery (93% vs 60%, P < 0.001), return for postpartum evaluation (80% vs 63%, P = 0.01), and have undetectable HIV viral load postpartum (50 copies per milliliter vs 2067, P < 0.0001). Conclusions: HCC can potentially reduce the risk of perinatal HIV transmission by improving maternal virologic control during pregnancy and postpartum and increasing postpartum contraceptive use.

Elevated systemic microbial translocation in pregnant HIV-infected women compared to HIV-uninfected women, and its inverse correlations with plasma progesterone levels

In HIV infection, increased adverse perinatal outcomes reported among HIV-associated pregnancies are not fully understood. Currently, microbial product translocation (MT) from a permeable mucosa is demonstrated as a driver of inflammation, and may contribute to preterm delivery in HIV. Here, our results showed that plasma LPS levels (a representative marker of MT) were increased in HIV-infected women in the first and second trimester. Progesterone levels were significantly decreased in HIV-infected subjects in the first trimester and second trimester. There were significant inverse correlations between plasma LPS and progesterone in the first and second trimester. These results suggested heightened systemic MT and decreased plasma progesterone levels in HIV-infected pregnant women may play a role in increased incidence of preterm delivery.

The Impact of HIV-Centered Obstetric Care on Perinatal Transmission and Linkage to Care in HIV-Infected Women [7F]

INTRODUCTION: The objective of this study was to determine the effects of HIV-centered obstetric care (HCC) on maternal and fetal outcomes. The primary outcome of interest is perinatal HIV transmission. METHODS: This was a retrospective cohort study HIV-infected women and their HIV-exposed infants who delivered from 2000 to 2014. Prior to 2009, women received care in a high risk pregnancy clinic (HRC). In 2009, a HCC service was established, staffed by obstetrician specialists with HIV medical training, a social worker, and a patient advocate. HIV-infected women delivering after 2009 received HCC. Maternal and neonatal outcomes, including perinatal HIV transmission rates, were compared between HIV-infected women receiving HRC compared to HCC. Continuous variables were compared with Students t test and Wilcoxon rank sum tests. Categorical variables were compared using &khgr;2 test and Fishers exact test. RESULTS: 161 women delivered 217 HIV-exposed pregnancies from 2000–2014; four women delivered twins (2%). Seventy-eight women (36%) received HCC. Three perinatal HIV transmissions (2%) occurred among women in HRC compared none in women receiving HCC. Women in HCC were more likely to have HIV RNA viral loads (VL) <1,000 at delivery (12% vs 26%, P=.02), use a long-acting reversible contraceptive (LARC) method (26% vs 2%, P<.0001), return for a postpartum visit (80% vs 63%, P=.01), and had lower median VL postpartum (40 copies/mL vs 1855, P<.0001). CONCLUSION: Implementing an HCC model may reduce perinatal HIV transmission, improve maternal virologic control during pregnancy, increase postpartum LARC use, and improve HIV care compliance.