Madeline Y. Sutton

The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health

Objectives: Bacterial vaginosis (BV), a disturbance of vaginal microflora, is a common cause of vaginal symptoms and is associated with an increased risk of acquisition of sexually transmitted infections, HIV, and with adverse pregnancy outcomes. We determined prevalence and associations with BV among a representative sample of women of reproductive age in the United States. Study Design: Women aged 14–49 years participating in the National Health and Nutrition Examination Survey 2001–2004 were asked to submit a self-collected vaginal swab for Gram staining. BV, determined using Nugent’s score, was defined as a score of 7–10. Results: The prevalence of BV was 29.2% (95% confidence interval 27.2%–31.3%) corresponding to 21 million women with BV; only 15.7% of the women with BV reported vaginal symptoms. Prevalence was 51.4% among non-Hispanic blacks, 31.9% among Mexican Americans, and 23.2% among non-Hispanic whites (P <0.01 for each comparison). Although BV was also associated with poverty (P <0.01), smoking (P <0.05), increasing body mass index (&khgr;2P <0.0001 for trend), and having had a female sex partner (P <0.005), in the multivariate model, BV only remained positively associated with race/ethnicity, increasing lifetime sex partners (&khgr;2P <0.001 for trend), increasing douching frequency (&khgr;2P for trend <0.001), low educational attainment (P <0.01), and inversely associated with current use of oral contraceptive pills (P <0.005). Conclusion: BV is a common condition; 84% of women with BV did not report symptoms. Because BV increases the risk of acquiring sexually transmitted infections, BV could contribute to racial disparities in these infections.

The Prevalence of Trichomonas vaginalis Infection among Reproductive-Age Women in the United States, 2001–2004

BACKGROUND Trichomonas vaginalis infection is a common sexually transmitted protozoal infection and is associated with several adverse health outcomes, such as preterm birth, delivery of a low-birth weight infant, and facilitation of sexual transmission of human immunodeficiency virus. The annual incidence in the United States has been estimated to be 3-5 million cases. However, there are no data on the prevalence of trichomoniasis among all reproductive-age women. We estimated the prevalence of T. vaginalis infection from a nationally representative sample of women in the United States. METHODS Women aged 14-49 years who participated in the National Health and Examination Survey cycles for 2001-2004 provided self-collected vaginal swab specimens. The vaginal fluids extracted from these swabs were evaluated for the presence of T. vaginalis using polymerase chain reaction. RESULTS Overall, 3754 (81%) of 4646 women provided swab specimens. The prevalence of T. vaginalis infection was 3.1% (95% confidence interval [CI], 2.3%-4.3%); for non-Hispanic white women, it was 1.3% (95% CI, 0.7%-2.3%); for Mexican American women, it was 1.8% (95% CI, 0.9%-3.7%); and for non-Hispanic black women, it was 13.3% (95% CI, 10.0%-17.7%). Factors that remained associated with increased likelihood of T. vaginalis infection in multivariable analyses included non-Hispanic black race/ethnicity, being born in the United States, a greater number of lifetime sex partners, increasing age, lower educational level, poverty, and douching. CONCLUSIONS The prevalence of T. vaginalis infection among women in the United States was 3.1%. A significant racial disparity exists; the prevalence among non-Hispanic black women was 10.3 times higher than that among non-Hispanic white and Mexican American women. Optimal prevention and control strategies for T. vaginalis infection should be explored as a means of closing the racial disparity gaps and decreasing adverse health outcomes due to T. vaginalis infection.

Trends in Pelvic Inflammatory Disease Hospital Discharges and Ambulatory Visits, United States, 1985–2001

Objective: The objective of this study was to describe the estimated trends in incidence of pelvic inflammatory disease (PID) among reproductive-aged women in hospital and ambulatory settings. Study: Analyses of PID estimates were performed. Three nationally representative surveys conducted by the National Center for Health Statistics (NCHS): National Hospital Discharge Survey (NHDS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and National Ambulatory Medical Care Survey (NAMCS), were used to obtain the estimates of PID (defined by International Classification of Diseases, 9th Revision codes). National Disease and Therapeutic Index (NDTI) estimates were reviewed for comparison. Results: Rates of hospitalized PID declined 68% overall from 1985 through 2001 (P <0.0001). Ambulatory data support a decrease in PID from 1985 to 2001. From 1995 to 2001, approximately 769,859 cases of acute and unspecified PID were diagnosed annually, 91% in ambulatory settings. Conclusions: PID has decreased in hospital and ambulatory settings. The expanded national surveys in outpatient and emergency departments provide more complete estimates for PID. Optimal management of PID should target ambulatory settings, where the majority of cases are diagnosed and treated.

A Review of the Centers for Disease Control and Prevention's Response to the HIV/AIDS Crisis Among Blacks in the United States, 1981–2009

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDCs efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obamas goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

Molecular Subtyping of Treponema pallidum in an Arizona County with Increasing Syphilis Morbidity: Use of Specimens from Ulcers and Blood

A molecular-based subtyping system for Treponema pallidum was used during an investigation of increasing syphilis in Maricopa County, Arizona. Genital ulcer or whole blood specimens from patients with syphilis were assayed by a polymerase chain reaction (PCR) amplification of a T. pallidum DNA polymerase I gene. Positive specimens were typed on the basis of PCR amplification of 2 variable genes. In all, 41 (93%) of 44 of ulcer specimens and 4 (27%) of 15 blood specimens yielded typeable T. pallidum DNA. Twenty-four (53%) of 45 specimens were subtype 14f; other subtypes identified included 4f, 4i, 5f, 12a, 12f, 14a, 14d, 14e, and 14i. Only 2 specimens were from epidemiologically linked patients. This investigation demonstrates that multiple subtypes of T. pallidum can be found in an area with high syphilis morbidity, although 1 subtype (14f) was predominant. Four typeable specimens were from blood, a newly identified specimen source for subtyping.

HIV/AIDS Prevention, Faith, and Spirituality among Black/African American and Latino Communities in the United States: Strengthening Scientific Faith-Based Efforts to Shift the Course of the Epidemic and Reduce HIV-Related Health Disparities

Black/African American and Latino communities are disproportionately affected by the domestic HIV/AIDS epidemic. Blacks/African Americans and Latinos are also more likely to report a formal, religious, or faith affiliation when compared with non-Hispanic whites. As such, faith leaders and their institutions have been identified in the National HIV/AIDS Strategy as having a vital role to serve in reducing: (1) HIV-related health disparities and (2) the number of new HIV infections by promoting non-judgmental support for persons living with and at risk for HIV/AIDS and by serving as trusted information resources for their congregants and communities. We describe faith doctrines and faith–science partnerships that are increasing in support of faith-based HIV prevention and service delivery activities and discuss the vital role of these faith-based efforts in highly affected black/African American and Latino communities.

HIV/AIDS Knowledge Scores and Perceptions of Risk Among African American Students Attending Historically Black Colleges and Universities

Objective. African American young adults are disproportionately affected by the HIV/AIDS epidemic and often unaware of their personal risk for HIV. Historically black colleges and universities (HBCUs) enroll 25% of college-educated African American young adults and can play an important role in HIV prevention. We examined HIV/AIDS knowledge of students at HBCUs to inform and strengthen our HIV prevention efforts at HBCUs. Methods. African American undergraduate HBCU students completed online surveys assessing HIV/AIDS knowledge and behaviors, and we analyzed data to assess their knowledge and behaviors. Results. A total of 1,051 of 1,230 surveys completed (85.4%) were analyzable. Eighty-two percent of students had average/high HIV knowledge scores. Seventy-nine percent of students surveyed perceived themselves to be at low risk for HIV infection; 64% of those who had at least two or more sex partners had not used a condom at last sex encounter. In the final model, significant independent effects were identified for average/high knowledge of HIV risk, including agreeing with assessing a potential partners HIV risk by all of the five actions listed (adjusted odds ratio [AOR] = 2.7, 95% confidence interval [CI] 1.7, 4.3) and never using a needle to inject drugs (AOR=5.6, 95% CI 3.2, 9.7). Conclusions. Educating students about effectively assessing sex partner risk will improve HIV knowledge and prevention efforts at HBCUs.

Missed Opportunities for HIV Testing in Health Care Settings Among Young African American Men Who Have Sex with Men: Implications for the HIV Epidemic

Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities.

Trichomoniasis in pregnant human immunodeficiency virus-infected and human immunodeficiency virus-uninfected congolese women: Prevalence, risk factors, and association with low birth weight

OBJECTIVE We sought to assess the prevalence of and risk factors for vaginal trichomoniasis in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected pregnant Congolese women and its relationship to pregnancy outcomes. STUDY DESIGN We performed a nested case-control study of 215 infected and 206 uninfected mothers who responded to questionnaires, underwent sexually transmitted disease testing (including culture for trichomoniasis shortly after delivery), and underwent assessment of infant outcomes. Maternal variables and birth outcomes were assessed according to presence or absence of trichomoniasis and human immunodeficiency virus. RESULTS Trichomoniasis was present in 18.6% of human immunodeficiency virus-positive and 10.2% of human immunodeficiency virus-negative women, respectively (odds ratio, 2.0; 95% confidence interval, 1.1-3.6), and was significantly associated with low birth weight (odds ratio, 2.4; 95% confidence interval, 1.2-4.5). In multivariate analyses trichomoniasis remained associated with low birth weight, and adjustments were made for other risk factors associated with low birth weight. CONCLUSION These findings suggest an association between trichomoniasis and low birth weight independent of human immunodeficiency virus infection and other risk factors. Further studies are needed to assess the impact of antenatal screening and treatment for trichomoniasis on pregnancy outcomes.

The sequence of the acidic repeat protein (arp) gene differentiates venereal from nonvenereal Treponema pallidum subspecies, and the gene has evolved under strong positive selection in the subspecies that causes syphilis

Despite the completion of the Treponema pallidum genome project, only minor genetic differences have been found between the subspecies that cause venereal syphilis (ssp. pallidum) and the nonvenereal diseases yaws (ssp. pertenue) and bejel (ssp. endemicum). In this paper, we describe sequence variation in the arp gene which allows straightforward differentiation of ssp. pallidum from the nonvenereal subspecies. We also present evidence that this region is subject to positive selection in ssp. pallidum, consistent with pressure from the immune system. Finally, the presence of multiple, but distinct, repeat motifs in both ssp. pallidum and Treponema paraluiscuniculi (the pathogen responsible for rabbit syphilis) suggests that a diverse repertoire of repeat motifs is associated with sexual transmission. This study suggests that variations in the number and sequence of repeat motifs in the arp gene have clinical, epidemiological, and evolutionary significance.