Dora Warren

The trading of sex for drugs or money and HIV seropositivity among female intravenous drug users

OBJECTIVES Data from 538 women in a cohort study recruited in 1988-1989 were analyzed to determined whether trading sex for drugs or money was independently associated with human immunodeficiency virus (HIV) seroprevalence in a population of female intravenous drug users. METHODS The women were grouped according to the number of partners with whom they reported trading sex for drugs or money during the previous 10 years: none, 1 through 49 (low), or 50 or more (high); the prevalence of HIV seropositivity in the three groups was 23.2%, 23.7%, and 47.6%, respectively. Logistic regression was used to compare the low- and high-trade groups separately with the group that reported no trading. RESULTS Low trading was not associated with seroprevalent HIV infection. In a multivariate model, high trading (compared with no trading) was significantly associated with HIV seropositivity after adjustment for cocaine use, history of sexually transmitted diseases, and duration of intravenous drug use. CONCLUSIONS These data indicate that, among intravenous drug-using women, high levels of trading sex for drugs or money were independently associated with HIV infection. This group needs to be targeted for further intensive intervention.

Prevalence of Lower Genital Tract Infections Among Human Immunodeficiency Virus (HIV)—Seropositive and High-Risk HIV-Seronegative Women

This study was undertaken to assess whether the prevalence of lower genital tract infections among human immunodeficiency virus (HIV)-seropositive women was higher than among high-risk HIV-seronegative women at their baseline visit for the HIV Epidemiology Research Study. Results were available for 851 HIV-seropositive and 434 HIV-seronegative women. Human papilloma virus (HPV) infection was more prevalent among HIV-seropositive women (64% vs. 28%). Bacterial vaginosis was common (35% vs. 33%), followed by trichomoniasis (12% vs. 10%), syphilis (8% vs. 6%), Chlamydia trachomatis infection (4% vs. 5%), candidal vaginitis (3% vs. 2%), and Neisseria gonorrhoeae infection (0.8% vs. 0.3%). Alcohol use (odds ratio [OR], 1.8; 95% confidence interval [CI], 1. 3-2.4) and smoking (OR, 1.8; 95% CI, 1.3-2.5) were associated with bacterial vaginosis. Bacterial vaginosis (OR, 2.3; 95% CI, 1.5-3.4), trichomoniasis (OR, 2.3; 95% CI, 1.1-4.7), and syphilis (OR, 3.1; 95% CI, 1.3-7.4) were found to be more prevalent among black women. Our study showed no statistically significant difference in the prevalence of lower genital tract infections except for HPV between HIV-infected and demographically and behaviorally similar HIV-uninfected high-risk women.

Mucosal Candidal Colonization and Candidiasis in Women with or at Risk for Human Immunodeficiency Virus Infection

The epidemiology of mucosal candidal colonization and candidiasis was studied in a multicenter cohort of 871 human immunodeficiency virus (HIV)-seropositive and 439 demographically and behaviorally similar HIV-seronegative women. Cross-sectional analyses at baseline revealed that oropharyngeal colonization with Candida species was more prevalent among seropositive women and among women reporting recent cigarette smoking and injection drug use. Oropharyngeal candidiasis was also more prevalent among seropositive women. Both oropharyngeal colonization and candidiasis were significantly associated with a lower median CD4 lymphocyte count among seropositive women. Vaginal candidal colonization was more prevalent among seropositive women and among those reporting recent injection drug use and current insulin or oral antihyperglycemic therapy. Vaginal candidiasis was equally likely to be diagnosed in seropositive and seronegative women and was not significantly related to recent sexual contact. Neither vaginal colonization nor candidiasis was significantly related to a lower median CD4 lymphocyte count among seropositive women. Baseline evaluation indicated differences in the epidemiology of oropharyngeal and vaginal candidal colonization and candidiasis in HIV-seropositive women and suggested possible variation in pathogenesis of candidal infection at these two mucosal sites.

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.

Effect of HIV infection on menstrual cycle length.

Summary: HIV serostatus and menstrual function were examined using prospectively collected menstrual data from 802 HIV‐seropositive and 273 HIV‐seronegative women, ages 20 to 44, enrolled in two cohort studies of HIV infection in North American women. The associations between HIV serostatus and the probabilities of having a cycle lasting >40 days (n = 541 cycles), >90 days (n = 67 cycles), <18 days (n = 316 cycles) and mean length and variability of 18 to 40 day cycles (n = 3634) were assessed. After adjustment for demographic characteristics, body mass index, and substance use, seropositivity increased the odds of having a very short cycle (<18 days, odds ratio [OR], 1.45; 95% confidence interval [CI], 1.00‐2.11) and a very long cycle (>90 days, OR, 1.32; 95% CI, 0.68‐2.58) slightly, although the latter CIs include one. Seropositivity did not increase the odds of having a moderately long cycle (>40 days, OR, 1.14) or affect mean cycle length or variability (&bgr;, 0.30 ± 0.20; between‐woman standard deviation [SD], 2.2 days [HIV‐seronegative] and 1.9 days [HIV‐seropositive]; within‐woman SD, 3.5 days for both). Although seropositivity may slightly increase the probability of very short cycles, HIV serostatus has little overall effect on amenorrhea, menstrual cycle length, or variability. Among HIV‐seropositive women, higher viral loads and lower CD4+ counts were associated with increased cycle variability and polymenorrhea.

Influence of Sex Hormones, HIV Status, and Concomitant Sexually Transmitted Infection on Cervicovaginal Inflammation

The impact of demographic characteristics, phase of the menstrual cycle, use of hormonal contraceptives, and concomitant lower genital-tract infections on cervicovaginal inflammatory cells was assessed in 967 women, 654 of whom were infected with human immunodeficiency virus type 1 (HIV-1). Cervicovaginal lavage (CVL) fluid was evaluated for total white blood cell (WBC), polymorphonuclear leukocyte, and monocyte counts. HIV-1 infection was not associated with statistically significant differences in numbers of inflammatory cells in CVL fluid except in 1 group--HIV-1-infected women with Chlamydia trachomatis infection had a 0.43 log(10) higher WBC count than their HIV-uninfected, chlamydia-positive counterparts (P=.04). Younger age and use of progesterone-based hormonal contraceptives were independently associated with increased numbers of inflammatory cells in CVL fluid. A 0.15-0.2 log(10) increase in inflammatory cells was seen in black versus white and Hispanic women after adjustment for known potential confounders. Progesterone-based contraceptives, younger age, and race have an independent effect on cervicovaginal inflammatory cells.

Transfusion transmission of cytomegalovirus confirmed by restriction endonuclease analysis

interactions between platelets and blood-vessel walls. N Engl J Med 1979;300:1142-47. 4. Leffler CW, Hessler JR, Terragno NA: Ventilation-induced release of prostaglandinlike material from fetal lungs. Am J Physiol 1980;238:H282-286. 5. Szczeklik J, Szczeklik A, Nizankowski R: Prostacyclin for pulmonary hypertension. Lancet 1980;2:1076. 6. Lock JE, Olley PM, Coceani F, Swyer PR, Rowe RD: Use of prostacyclin in persistent fetal circulation. Lancet 1979; I:1343. 7. Leftter CW, Hessler JR: Pulmonary and systemic vascular effects of exogenous prostaglandin 12 in fetal lambs. Eur J Pharmacol 1979;54:37-42. 8. Lock JE, Olley PM, Coceani F: Direct pulmonary vascular responses to prostaglandins in the conscious newborn lamb. Am J Physiol 1980;238:H631-638. 9. Coceani F, Olley PM: Prostaglandins and the circulation at birth. In: Herman AG, Vanhoulte PM, Denolin H, Goosens A, eds: Cardiovascular pharmacology of the prostagtandins. New York: Raven Press, 1982;303-314. 10. Watkins WD, Peterson MB, Crone RK, Shannon DC, Levine L: Prostacyclin and prostaglandin El for severe idiopathic pulmonary hypertension. Lancet 1980; l : 1083. 11. Szczeklik J, Szczeklik A, Nizankowski R: Hemodynamic changes induced by prostacyclin in man. Br Heart J 1980; 44:254-8. 12. Fox WW, Duara S: Persistent pulmonary hypertension in the neonate: diagnosis and management. J PEDIATR 1983; 103:505-8. 13. Drummond WH, Williams B J, Panchard WB, Bucholz C J, Bucholz CL: Myocardial infarction after prostacyclin (PGIz) treatment of neonatal pulmonary hypertension. Pediatr Res 1982;16:99A.

A multicenter study of bacterial vaginosis in women with or at risk for human immunodeficiency virus infection

Background: Bacterial vaginosis is a common gynecologic infection that has been associated with a variety of gynecologic and obstetric complications, including pelvic inflammatory disease, postabortal infection and premature delivery. Recent studies suggest that bacterial vaginosis may increase a woman’s risk for human immunodeficiency virus (HIV). We undertook this study to assess whether the prevalence and characteristics of bacterial vaginosis differed according to HIV status in high-risk US women. Methods: Prevalence of bacterial vaginosis was assessed by Gram’s stain and clinical criteria for 854 HIV-infected and 434 HIV-uninfected women enrolled in the HIV Epidemiology Research (HER) Study.Multiple logistic regression techniques were used to determine whether HIV infection independently predicted bacterial vaginosis. Results: Almost half (46%) the women had bacterial vaginosis by Gram’s stain. The prevalence of bacterial vaginosis was 47% in the HIV-positive women compared with 44% in the HIV-negativewomen; this difference was not statistically significant (p = 0.36). After adjustment for other covariates, HIV-positive women were more likely than HIV-negative women to have bacterial vaginosis (odds ratio (OR) 1.31; 95% confidence interval (CI) 1.01-1.70) by Grams stain but not by clinical criteria (OR 1.16; CI 0.87-1.55). Among HIV-positive women, use of antiretroviral drugs was associated with a lower prevalence of bacterial vaginosis (adjusted OR 0.54; Cl 0.38 -0.77). Conclusions: In this cross-sectional analysis of high-risk US women, HIV infection was positively correlated with bacterial vaginosis diagnosed by Gram’s stain.

Comparison of clinical manifestations of HIV infection among women by risk group, CD4+ cell count, and HIV-1 plasma viral load

OBJECTIVES To compare the prevalence of HIV-related symptoms, physical examination findings, and hematologic variables among women whose risk for HIV is injection drug use since 1985 as opposed to sexual contact and to evaluate the influence of HIV plasma viral load and CD4+ cell count on clinical manifestations according to risk. METHODS Participants of the HIV Epidemiology Research Study (HERS; a multicenter, prospective, controlled study of HIV infection in women) were administered a risk behavior and symptom interview, underwent a physical examination, and received hematologic testing, including CD4+ cell counts done on study entry. Plasma HIV-1 viral loads were performed on stored frozen plasma using an ultrasensitive branched-DNA (b-DNA) signal amplification assay. CD4+ counts were categorized as <200 cells/microl, 200 to 499 cells/microl, or > or =500 cells/microl, and HIV viral loads were characterized in tertiles. RESULTS Cross-sectional analysis was conducted on data available for 724 HIV-infected women: 387 had a history of intravenous drug use and 337 were infected through heterosexual contact. The median CD4+ count was 376 cells/microl; the median HIV-1 viral load was 1135 copies/ml; and 281 of 724 HIV-infected women (38.8%) had an undetectable HIV-1 viral load. In analyses adjusting for CD4+ cell level alone and for plasma viral load combined with CD4+ cell level, injection drug users (IDUs) were more likely than those infected through heterosexual contact to report a recent episode of memory loss and weight loss, but less likely to have recent episodes of genital herpes; to have enlarged livers and a body mass index (BMI) <24, and to have hematocrit levels <34% and platelet counts <150,000 cells/ml. After adjustment for CD4+ cell level and risk group, high and medium HIV-1 plasma viral load levels were associated with the presence of oral hairy leukoplakia on examination, and only the highest level of plasma viral load was associated with recent histories of fever and thrush, oral hairy leukoplakia, pseudomembranous candidiasis, and BMI <24 on examination, and hematocrit <34%. CONCLUSIONS In this cohort of women, the distribution of HIV-1 plasma viral load was lower than that previously reported in populations of HIV-infected men. This study also shows some differences in frequency of signs, symptoms, and laboratory values between risk groups of HIV-infected women, but these results may be due to effects of injection drug use rather than HIV infection. Signs and symptoms identified as associated with increasing levels of viral load that were not different across risk groups suggest more direct association of these findings with HIV infection.

HIV infection in non-pregnant women: a review of current knowledge.

HIV infection has become an important health problem among American women. The natural history of HIV infection and AIDS appears to be similar for women and men, and preliminary studies demonstrate similar survival and clinical events for both sexes. The natural history and presentation of common gynecologic infections and conditions may be altered by HIV. Most is known about cervical dysplasia. The risk of cervical dysplasia appears to be increased in women with HIV infection, progression of cervical dysplasia may be more rapid, severity of disease increased, particularly for women with HIV-related immunocompromise. Recently, the Centers for Disease Control and Prevention added invasive cervical cancer as an AIDS-defining condition. Vulvovaginal candidiasis, sexually transmitted diseases, including syphilis, herpes, and cytomegalovirus, and pelvic inflammatory disease are also common in HIV-infected women. Preliminary data suggest that these conditions may be more severe and more difficult to treat in HIV-infected women than uninfected women. Women who are HIV-infected should have thorough evaluation and follow up of all gynecologic conditions, particularly as they become immunosuppressed.