Somchai Sriplienchan

A new circulating recombinant form, CRF15_01B, reinforces the linkage between IDU and heterosexual epidemics in Thailand.

HIV-1 subtype B and CRF01_AE have been in circulation in Thailand and Southeast Asia for more than a decade. Initially separated by risk group, the two strains are increasingly intermixed, and two recombinant strains of essentially reciprocal structure have been recently reported. Here we identify additional CRF_01B recombinants and provide the evidence that HIV-1 strains now pass freely between the two high-risk populations. HIV isolates that showed discordance between CRF01_AE and subtype B in multi-region genotyping assays were selected for the study. They were drawn from 3 different cohorts in Thailand representing different risk behaviors and demographic characteristics: a drug user cohort in the north, a family planning clinic attendee cohort in the southeast, and a cohort study of the mucosal virology and immunology of HIV-1 infection in Thailand. The DNA from these isolates was PCR amplified to recover the full HIV-1 genome and subjected to sequencing and phylogenetic analysis. We establish that one particular CRF_01B recombinant, with the external envelope of subtype B and the rest of the genome from CRF01_AE, is circulating widely in Thailand. Termed CRF15_01B (also referred to as CRF15), the strain was primarily heterosexually transmitted, although injecting drug use (IDU) also played a role. In aggregate data from the studies, CRF15 constituted 1.7% of all HIV-1 infections (95% confidence interval 0.5-4.4%) and was dispersed widely in the country. The previously separate heterosexual and IDU epidemics have apparently been bridged by a new CRF. The entry of CRF15 into the mainstream of the epidemic signals new complexity in the long stable molecular picture in Thailand. These recombinants must be considered in ongoing or projected efficacy evaluations of HIV-1 vaccines and antiviral therapies.

Combined oral contraceptive use increases HPV persistence but not new HPV detection in a cohort of women from Thailand.

BACKGROUND Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear how COC use impacts risk of cervical carcinogenesis. METHODS We estimated the risk of new human papillomavirus (HPV) DNA detection and persistence among 1135 human immunodeficiency virus (HIV)-negative women aged 20-37 years from Thailand who were followed for 18 months at 6-month intervals. Type-specific HPV DNA, demographic information, hormonal contraceptive use, sexual behavior, genital tract coinfection, and Papanicolaou test results were assessed at baseline and each follow-up. RESULTS Women who reported current COC use during follow-up were less likely to clear HPV infection compared with nonusers, independent of sexual behavior, and Papanicolaou test diagnosis (AHR: 0.67 [95% CI: .49-.93]). Similar associations were not observed among women reporting current use of depomedroxyprogesterone acetate (DMPA). Neither COC nor DMPA use was significantly associated with new HPV DNA detection. CONCLUSIONS These data do not support the hypothesis that contraceptive use is associated with cervical cancer risk via increased risk of HPV acquisition. The increased risk of HPV persistence observed among current COC users suggests a possible influence of female sex hormones on host response to HPV infection.

The association of hormonal contraceptive use and HPV prevalence.

Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear whether COC use is associated with upstream events of human papillomavirus (HPV) infection prior to development of clinical disease. The objective of our study was to assess the association of contraceptive use on the risk for prevalent HPV infection in a cohort of long‐term hormonal contraceptive (HC) users. One thousand and seventy (n = 1,070) HIV‐negative women aged 20–37 from Thailand enrolled in a prospective study of the natural history of HPV. Baseline HPV genotype information, recency and duration of HC use, sexual behavior, other sexually transmitted infection (STI) information and cervical cytology and histology were assessed. At enrollment, 19.8% and 11.5% of women were infected with any HPV or any high‐risk (HR)‐HPV, respectively. After adjustment for age, current and past sexual risk behaviors, STI history and cytology, the use of COCs for >6 years was found to be associated with an increased risk of infection with any HPV [prevalence ratio (PR): 1.88 (1.21, 2.90)] and any HR‐HPV [PR: 2.68 (1.47, 4.88)] as compared to never users. Recent, long‐term COC use was associated with an increased risk for prevalent HPV infection independent of sexual behavior and cervical abnormalities. No similar association was observed for recent or long duration use of progestin‐only contraceptives (i.e., depomedroxyprogesterone acetate). These data suggest that COC use may impact early upstream events in the natural history of HPV infection.

Discontinuation of oral contraceptives and depot medroxyprogesterone acetate among women with and without HIV in Uganda, Zimbabwe and Thailand

BACKGROUND We examined hormonal contraceptive (HC) discontinuation and factors associated with discontinuation among HIV-uninfected women and the effect of HIV diagnosis on subsequent contraceptive use. STUDY DESIGN We analyzed 4461 HIV-uninfected women from a prospective study of HC and HIV acquisition in Uganda, Zimbabwe and Thailand. Participants were ages 18-35 years, not pregnant, and using oral contraceptives (OCs) or injectable depot medroxyprogesterone acetate (DMPA) for at least 3 months before enrollment (median duration of OC and DMPA use before enrollment was 11.7 and 8.9 months, respectively). We compared the probability of OC and DMPA discontinuation using survival analysis and factors related to discontinuation using Cox regression. We also analyzed contraceptive patterns among 194 women who became infected with HIV. RESULTS Median duration of use after study enrollment was 15.6 months for OCs and 18.5 months for DMPA. Continuation rates for both methods were highest in Thailand. Factors associated with OC discontinuation included, nausea, breast tenderness, condom use, and no sex. Factors associated with DMPA discontinuation included young age, breast tenderness, nausea, irregular bleeding, high-risk sexual behaviors, partner risk, condom use, and no sex. Following an HIV diagnosis, 135 (98.5%) of 137 hormonal users continued HC and 14 (25%) of 57 nonusers began using HC. CONCLUSIONS Contraceptive continuation for OCs and DMPA was relatively high over 2 years. Young women, those reporting side effects, and those using condoms are more likely to discontinue and need ongoing contraceptive counseling. Many women receiving HIV-positive diagnoses desire effective contraception.

Pregnancy risk among oral contraceptive pill injectable contraceptive and condom users in Uganda Zimbabwe and Thailand.

OBJECTIVE: To estimate the probability of pregnancy for oral contraceptive pill (OCP), injectable contraceptive, and condom users in Uganda, Thailand, and Zimbabwe. METHODS: This study is a secondary analysis of 5,224 women who participated in a prospective study evaluating the association between hormonal contraception and human immunodeficiency virus (HIV) acquisition. RESULTS: The overall 12-month cumulative probability of pregnancy of injectable contraceptive users was 0.6% (95% confidence interval [CI] 0.3–1.0), with similar risks in Uganda (0.3%, 95% CI 0–0.7), Thailand (0.6%, 95% CI 0–1.2), and Zimbabwe (1.0%, 95% CI 0.3–1.7). The 12-month cumulative probability of pregnancy for OCP users was 9.5% (95% CI 8.1–11.0%), with similar risks of pregnancy in Uganda and Zimbabwe (14.6%, 95% CI 11.7–17.4; and 10.2%, 95% CI 8.0–12.5, respectively) but substantially lower risk in Thailand (0.5%, 95% CI 0–1.2). The overall 12-month cumulative probability of pregnancy for women intending to use a given method at baseline was 2.0% (95% CI 1.4–2.6%) for injectable contraceptives, 15.7% (95% CI 14.1–17.3%) for OCPs, and 25.8% (95% CI 23.2–28.4) for condoms. Women in Thailand experienced lower pregnancy risk with condoms (18.4%, 95% CI 11.1–25.7) than in Uganda (29.5%, 95% CI 25.7–33.4), and Zimbabwe (23.3%, 95% CI 19.4–27.2). CONCLUSION: The overall risk of pregnancy for injectable contraceptive users was substantially lower than for oral contraceptive pill users. However, Thai participants had similarly low cumulative pregnancy probabilities for both methods. Women receiving contraceptive counseling should be informed that their experience with a given method may differ from the average or typical-use pregnancy rates often discussed during contraceptive counseling. Tailored counseling is necessary for women to make informed choices. LEVEL OF EVIDENCE: II

Risk factors for bacterial vaginosis incidence in young adult thai women

Objective: To determine risk factors for incident bacterial vaginosis (BV) in young Thai women. Study Design: Prospective data from a cohort of 1522 women aged 18 to 35 years, who were enrolled in a study of hormonal contraception and HIV acquisition, were used to evaluate potential risk factors for BV, as diagnosed by Amsel criteria. Results: The median prevalence of BV from 3 to 24 months of follow-up visits was 2.5%. The BV incidence was 10.0 per 100-woman years. Statistically significant factors in multivariable analysis were sex during menstruation [hazard ratio (HR), 1.80; 95% CI, 1.11–2.92], male partners having sex with other women (HR, 2.3; 95% CI, 1.45–2.98), cigarette smoking (HR, 1.79; 95% CI, 1.08–2.98), and trichomoniasis (HR, 15.68; 95% CI, 4.95–49.68). Intravaginal practices were not associated with incident BV in unadjusted or adjusted analysis. Conclusions: This study supports the association between sexual behaviors and the incident BV. Failure to detect an association between intravaginal practices and incident BV warrants further studies in high-risk populations or in women with a higher prevalence of intravaginal practices.

Prevalence and correlates of HPV among women attending family-planning clinics in Thailand

BackgroundCervical cancer is the most common cancer among women of reproductive age in Thailand. However, information on the prevalence and correlates of anogenital HPV infection in Thailand is sparse.MethodsHPV genotype information, reproductive factors, sexual behavior, other STI and clinical information, and cervical cytology and histology were assessed at enrollment among one thousand two hundred and fifty-six (n = 1,256) HIV negative women aged 20–37 from Thailand enrolled in a prospective study of the natural history of HPV. The type-specific prevalence of HPV was estimated using cervical swab specimens from healthy women and women with a diagnosis of CIN 2/3 at baseline. Prevalence ratios (95% CI) were estimated using Poisson regression to quantify the association of demographic, behavioral, and clinical correlates with prevalent HPV infection.ResultsOverall, 307 (24.6%) and 175 (14.0%) of women were positive for any HPV type and any HR-HPV type, respectively; the most common types were 72, 52, 62, and 16. Among women diagnosed with CIN 2/3 at enrollment (n = 11), the most prevalent HPV types were 52 and 16. In multivariate analysis, HPV prevalence at enrollment was higher among women with: long-term combined oral contraceptive use, a higher number of lifetime sexual partners, a prior Chlamydia infection, and a current diagnosis of Bacterial Vaginosis.ConclusionThe study findings provide important information that can be used in the evaluation of primary and secondary interventions designed to reduce the burden of cervical cancer in Thailand.

Confirmation and quantitation of human papillomavirus type 52 by Roche Linear Array using HPV52-specific TaqMan E6/E7 quantitative real-time PCR.

Human papillomavirus type 52 is highly prevalent in Asia and Africa and accounts for 2-3% of total cervical cancer burden worldwide. The Roche Molecular Systems HPV Linear Array (RMS-LA uses multiple type (i.e. mixed) probes to detect DNA from HPV 52 infection which limits the assays ability to determine HPV 52 status in the presence of HPV 33, 35, or 58 infection. This report presents a simple to use and highly reproducible HPV 52 type-specific quantitative real-time PCR (RT-PCR) assay based on Taqman chemistry for detection and quantification of HPV 52 DNA from cervical swab specimens. Mixed probe positive cervical swab specimens collected from rural and urban women in Thailand (n=68) were used to determine assay agreement and differences in HPV 52 DNA viral load across cytological diagnosis. Forty-eight specimens were determined to be HPV 52 positive by RMS-LA with 94% (n=45) confirmed positive by Taqman assay (kappa: 0.86, 95% CI: 0.74, 0.99). Higher median viral load was observed among women with a Pap diagnosis of >=ASCUS vs. normal/inflammation (8510 copies/1000 cell equivalents vs. 279 copies/1000 cell equivalents, p<0.05). Accurate ascertainment of infection status is important in understanding HPV 52s role in the etiology of cervical cancer as well as for the development of type-specific vaccines.

Kinetics of DNA load predict HPV 16 viral clearance

INTRODUCTION While high HPV 16 viral load measured at a single time point is associated with cervical disease outcomes, few studies have assessed changes in HPV 16 viral load on viral clearance. OBJECTIVE To measure the association between changes in HPV 16 viral load and viral clearance in a cohort of Thai women infected with HPV 16. STUDY DESIGN Fifty women (n=50) between the ages of 18-35 years enrolled in a prospective cohort study were followed up every three months for two years. Women positive for HPV 16 DNA by multiplex TaqMan assay at two or more study visits were selected for viral load quantitation using a type-specific TaqMan based real-time PCR assay. The strength of the association of change in viral load between two visits and viral clearance at the subsequent visit was assessed using a GEE model for binary outcomes. RESULTS At study entry, HPV 16 viral load did not vary by infection outcome. A >2 log decline in viral load across two study visits was found to be strongly associated with viral clearance (AOR: 5.5, 95% CI: 1.4-21.3). HPV 16 viral load measured at a single time point was not associated with viral clearance. CONCLUSIONS These results demonstrate that repeated measurement of HPV 16 viral load may be a useful predictor in determining the outcome of early endpoints of viral infection.

Detection of human papillomavirus from self-collected vaginal samples of women in Chiang Mai, Thailand.

IT HAS BEEN SHOWN THAT some types of human papillomavirus (HPV) are the major risk factor for high-grade squamous intraepithelial lesion and invasive cervical carcinoma.1,2 The detection of HPV has been used as an adjunct to cervical cytology to identify women who are at risk of developing cervical cancer.2 Currently, the most widely used method to detect HPV DNA is by obtaining a specimen from cervix. However, some studies have shown that HPV detection by self-collected vaginal swab is comparable to virus detection in swabs obtained directly from the cervix.3,4 The self-collected vaginal samples also offer advantages over endocervical swabs in term of acceptability to clients and in reducing the need for trained personnel and clinical materials required for a cervical sample collection.4,5 The self-collected sample for HPV detection seems to offer a potential opportunity for more widely accessible cancer prevention and for populationbased molecular epidemiologic research. We conducted the study of HPV infection among women from communities in Chiang Mai, Thailand, using self-collected vaginal samples. Five hundred thirty-one sexually active women aged 20 to 65 years participated in the study. They were selected by nonprobability sampling method from 8 communities located within 50 km of Chiang Mai city. Written informed consent was obtained from all women; the protocol was reviewed and approved by the relevant Institutional Review Boards. The women were asked to provide their vaginal sample for HPV testing. The women were given a sample collection kit (swab specimen collection kit, Digene Corp, Beltsville, MD) that was composed of a sterile Dacron swab in a wrapper and a plastic vial containing specimen transport media. Verbal and written instructions for cell collection were provided. In brief, women were asked to insert a collection swab gently into the vagina about halfway in or until meeting with resistance; then they were to rotate the swab 3 turns in the same direction, take the swab out, and put it in the transport vial. The samples were transported to the laboratory and tested for HPV DNA and HPV typing. The DNA of vaginal samples was extracted and amplified using PGMY09-PGMY11 biotinylated L1 consensus primers, generating a 450-base pair amplicon.6 To determine specimen adequacy, the biotinylated -GH20/ -PC04 human -globin target was coamplified, generating a 250-base pair amplicon. The results of amplification were confirmed by agarose gel electrophoresis. The genotypes of HPV were determined by the reverse line blot hybridization method.7 The HPV genotyping strip detects 2 -globin concentrations (high and low) and 38 HPV types: 22 putative high-risk types (16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56,58, 59, 66, 67, 68, 69, 70, 73, 82, IS39) and 16 low-risk types (6, 11, 40, 42, 54, 55, 57, 61, 62, 64, 71, 72, 81, 83, 84, CP6108). The classification of highand low-risk types was primarily based on International Agency for Research on Cancer (IARC)8 and also referred to the HPV reference guide provided by Roche. All of the women we approached were interested in collecting their vaginal samples for HPV testing. About 9.4% (50 of 531) of the samples lacked -globin control amplification. We therefore diluted the DNA template of these 50 samples with TE buffer (1:10) (TE 20 mM Tris-HC1, 1 mM EDTA [pH 8.0]) and repeated the polymerase chain reaction (PCR), and subsequently every sample could be amplified and produced a -globin PCR product. Of 531 women tested, 61 were positive for HPV DNA, and the overall HPV prevalence was 11.5% (Table 1). The prevThe authors gratefully acknowledge the Roche Molecular System, USA, for the donation of reagents and supplies for HPV detection and HPV typing. This work was supported, in part, by a fellowship/grant from the Fogarty International Center/USNIH, Johns Hopkins University, Grant 2 D 43 TW000010-18-AITRP. Correspondence: Kanlaya Wongworapat, MSc, 110 Intavaroros Road, Tambol Sriphum, Chiang Mai 50202 Thailand. E-mail: kanlaya@ chiangmai.ac.th. Received for publication November 10, 2006, and accepted August 16, 2007. From the *Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand; and †Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Sexually Transmitted Diseases, February 2008, Vol. 35, No. 2, p.172–173 DOI: 10.1097/OLQ.0b013e318158af65 Copyright