Incidence of three sexually transmitted diseases during a safer sex promotion program for HIV-infected women

Longitudinal effects of SafeTalk, a motivational interviewing-based program to improve safer sex practices among people living with HIV/AIDS

Programs to help people living with HIV/AIDS practice safer sex are needed to prevent transmission of HIV and other sexually transmitted infections. We sought to assess the impact of SafeTalk, a multicomponent motivational interviewing-based safer sex program, on HIV-infected patients' risky sexual behavior. We enrolled sexually active adult HIV-infected patients from one of three clinical sites in North Carolina and randomized them to receive the 4-session SafeTalk intervention versus a hearthealthy attention-control. There was no significant difference in the proportion of people having unprotected sex between the two arms at enrollment. SafeTalk significantly reduced the number of unprotected sex acts with at-risk partners from baseline, while in controls the number of unprotected sex acts increased. Motivational interviewing can provide an effective, flexible prevention intervention for a heterogeneous group of people living with HIV.

Factors associated with sexual risk behavior among persons living with HIV: gender and sexual identity group differences

Factors associated with HIV transmission risk may differ between subgroups of persons living with HIV/AIDS (PLWHA). This study examined such factors in a sample of PLWHA recruited in 3 US metropolitan areas. Sexually active participants were categorized as gay or bisexual men (GBM) (n = 545), heterosexual men (HSM, n = 223), or women (n = 214). Of 982 participants, 27.1% reported serodiscordant unprotected anal or vaginal sex (SDUAV). SDUAV was associated with multiple (2 or more) partners, using poppers, and lower safer sex self-efficacy among GBM. SDUAV was associated with multiple partners among HSM. Among women, factors examined were not associated with SDUAV. These findings are consistent with prior research and facilitate our ability to target those who may be most at risk for transmitting HIV among HIV-positive GBM. More research must be conducted to identify factors associated with risk behavior among HSM and women.

Early repeated infections with Trichomonas vaginalis among HIV-positive and HIV-negative women

BACKGROUND

The purpose of the study was to examine whether early repeated infections due to Trichomonas vaginalis among human immunuodeficiency virus (HIV)-positive and HIV-negative women are reinfections, new infections, or cases of treatment failure.

METHODS

Women attending an HIV outpatient clinic and a family planning clinic in New Orleans, Louisiana, who had culture results positive for T. vaginalis were treated with 2 g of metronidazole under directly observed therapy. At 1 month, detailed sexual exposure and sexual partner treatment information was collected. Isolates from women who had clinical resistance (i.e., who tested positive for a third time after treatment at a higher dose) were tested for metronidazole susceptibility in vitro.

RESULTS

Of 60 HIV-positive women with trichomoniasis, 11 (18.3%) were T. vaginalis positive 1 month after treatment. The 11 recurrences were classified as 3 probable reinfections (27%), 2 probable infections from a new sexual partner (18%), and 6 probable treatment failures (55%); 2 of the 6 patients who experienced probable treatment failure had isolates with mild resistance to metronidazole. Of 301 HIV-negative women, 24 (8.0%) were T. vaginalis positive 1 month after treatment. The 24 recurrences were classified as 2 probable reinfections (8%) and 22 probable treatment failures (92%); of the 22 patients who experienced probable treatment failure, 2 had strains with moderate resistance to metronidazole, and 1 had a strain with mild resistance to metronidazole.

CONCLUSION

HIV-positive women were more likely to have sexual re-exposure than were HIV-negative women, although the rate of treatment failure was similar in both groups. High rates of treatment failure among both HIV-positive and HIV-negative women indicate that a 2-g dose of metronidazole may not be adequate for treatment of some women and that rescreening should be considered.

Associations Between Recent Gender-Based Violence and Pregnancy, Sexually Transmitted Infections, Condom Use Practices, and Negotiation of Sexual Practices Among HIV-Positive Women

BACKGROUND

This study sought to document the prevalence of recent gender-based violence (rGBV) among seropositive women and to determine the association between rGBV and pregnancy, sexually transmitted infections (STIs), condom use, and negotiation of sexual practices.

METHODS

A total of 304 seropositive women recruited from HIV clinics in the southeastern United States who reported being sexually active in the previous 6 months with 1 partner were included in analyses. Gender-based violence during the previous 3 months, condom use, and negotiation of sexual practices were assessed. Biologic samples for pregnancy and STI testing were collected.

RESULTS

A total of 10.2% of women reported a history of rGBV. rGBV was related to inconsistent condom use practices, pregnancy, and abuse stemming from requests for condom use. No associations were found between rGBV and negotiation of sexual practices and STIs.

CONCLUSIONS

The prevalence of rGBV among HIV-positive women emphasizes the need for screening of abuse and highlights the need for the design and implementation of integrated intervention approaches necessary in addressing the needs of this population.

Alcohol consumption, ART usage and high-risk sex among women infected with HIV

We examine the role of alcohol consumption on sexual risk behavior among a cohort of 187 sexually active HIV-infected women (aged 18-61) in care at an urban ambulatory clinic in New Orleans, Louisiana, U.S. Sexual risk behavior among women on and off antiretroviral therapy (ART) and the relationship between alcohol use, ART, and behavior was also explored. One-fourth of respondents were classified as binge drinkers and the average number of drinking occasions per week ranged from none to 10-12. Approximately 60% were prescribed ART and self-reported adherence was 90%. One-third of the women reported no condom use at last vaginal sex, 62% reported inconsistent condom use for vaginal sex, and 7% had multiple male sex partners in the last month. Binge alcohol users and women on ART were significantly more likely to participate in each sexual risk outcome examined. Partner refusal of condom use was also significantly associated with binge drinking patterns. Results lend strength to the equivocal literature on the relationship between both alcohol and prescription of ART and sexual behavior. Enhanced detection of alcohol abuse, coupled with risk reduction counseling especially among women prescribed ART are important clinical practices in treating women with HIV.

Unprotected intercourse among people living with HIV/AIDS: The importance of partnership characteristics

The purpose of this study was to determine the relative importance and interactive effects of partnership characteristics in unprotected intercourse among people living with HIV/AIDS (PLWHA). An interview study was conducted among a convenience sample of PLWHA in care. Of all the demographic, health status, risk history and behaviors and partnership covariates explored, only the partnership covariates were significantly associated with unprotected intercourse. Significant covariates included having a steady partner (OR and 95%CI = 4.2; 1.3, 13.5), HIV-positive (OR and 95%CI = 2.7; 1.0, 6.9 versus HIV-negative partner) or unknown serostatus partner (OR and 95%CI = 4.6; 1.1, 18.3 versus HIV-negative partner) and men who have sex with men (MSM) partnerships (OR and 95%CI = 3.0; 1.2, 7.3). Partnership covariates explained 23% of the variance in unprotected intercourse; other groups of covariates did not significantly improve model fit. Significant interaction terms between reported partner HIV status, partnership type and sexual orientation revealed the greatest likelihood of unprotected intercourse in two groups of individuals: those in steady relationships with HIV-positive partners and MSM in relationships with partners of unknown serostatus. Prevention interventions for PLWHA should focus on partnership characteristics.

A randomized controlled trial to reduce HIV transmission risk behaviors and sexually transmitted diseases among women living with HIV: The WiLLOW Program

OBJECTIVE

To evaluate the efficacy of an intervention to reduce HIV transmission risk behaviors and sexually transmitted diseases (STDs) and enhance HIV-preventive psychosocial and structural factors among women living with HIV.

DESIGN

A randomized controlled trial of 366 women living with HIV in Alabama and Georgia.

INTERVENTION

The intervention emphasized gender pride, maintaining current and identifying new network members, HIV transmission knowledge, communication and condom use skills, and healthy relationships.

PRIMARY OUTCOME

Unprotected vaginal intercourse. OTHER OUTCOMES: Proportion never used condoms, incident STDs, psychosocial factors, and number of supportive network members.

RESULTS

Over the 12-month follow-up, women in the WiLLOW intervention, relative to the comparison, reported fewer episodes of unprotected vaginal intercourse (1.8 vs. 2.5; P = 0.022); were less likely to report never using condoms (odds ratio [OR] = 0.27; P = 0.008); had a lower incidence of bacterial infections (Chlamydia and gonorrhea) (OR = 0.19; P = 0.006); reported greater HIV knowledge and condom use self-efficacy, more network members, fewer beliefs that condoms interfere with sex, and fewer partner-related barriers to condom use; and demonstrated greater skill in using condoms.

CONCLUSION

This is the first trial to demonstrate reductions in risky sexual behavior and incident bacterial STDs and to enhance HIV-preventive psychosocial and structural factors among women living with HIV.

Importance of Sex Partner HIV Status in HIV Risk Assessment Among Men Who have Sex With Men

Clinical HIV risk assessments have not typically integrated questions about sex partners' HIV status with questions about condom use and type of sex. Since 2001, we have asked all men who have sex with men (MSM) evaluated in an urban sexually transmitted disease (STD) clinic how often in the preceding 12 months they used condoms for anal sex with partners who were HIV-positive, HIV-negative, and of unknown HIV status. Overall, MSM displayed a pattern of assortative mixing by HIV status, particularly for unprotected anal intercourse (UAI). Nevertheless, 433 (27%) of 1580 MSM who denied knowing they were HIV-positive and 93 (43%) of 217 HIV-positive MSM reported having UAI with a partner of opposite or unknown HIV status. Among men who denied previously knowing they were HIV-positive, 24 (9.6%) of 251 MSM who reported having UAI with an HIV-positive partner or partner of unknown HIV status compared with 11 (1.7%) of 620 MSM who denied such exposure tested HIV-positive (odds ratio=5.8, 95% confidence interval: 2.8-12.1). UAI with an HIV-positive partner or partner with unknown HIV status was 69% sensitive and 73% specific in identifying men with previously undiagnosed HIV infection; UAI regardless of partner HIV status was 80% sensitive but only 45% specific. The positive predictive value was highest for risk assessments that included partner HIV status. Integrating questions about anal sex partner HIV status and condom use identifies MSM at greatest risk for HIV acquisition and transmission. These risk criteria might be effectively used to triage MSM into more intensive prevention interventions.

Incidence and predictors of reinfection with Trichomonas vaginalis in HIV-infected women

BACKGROUND AND OBJECTIVES

The presence of sexually transmitted infections (STIs) may facilitate transmission of HIV to uninfected partners.

GOAL

To describe the incidence of reinfection with Trichomonas vaginalis in HIV-infected women and to assess predictors of reinfection.

STUDY DESIGN

A retrospective cohort study using data abstracted from medical records of HIV-infected women with at least one diagnosis of trichomoniasis.

RESULTS

Approximately one third (36%) of the study population was reinfected with T vaginalis during the follow-up period, with an incidence of 16.4 reinfections per 100 person years. Significant predictors of reinfection included history of another STI (hazard ratio, 1.52; 95% CI, 1.08-2.14) and becoming pregnant during the follow-up period (hazard ratio, 0.59; 95% CI, 0.39-0.87).

CONCLUSIONS

There is a high rate of reinfection with T vaginalis in HIV-infected women. Further research that includes information on sexual partners should be conducted to better describe the reinfection patterns of trichomoniasis.

Sexually transmitted infections in European HIV-infected women: incidence in relation to time from infection. European Study on the Natural History of HIV Infection in Women

OBJECTIVES

To investigate the prevalence and incidence of sexually transmitted infections (STI) in HIV-infected women in relation to time from infection and sexual behaviour.

DESIGN

The European study on the natural history of HIV infection in women is a prospective cohort study of 487 HIV-infected women with a known interval of seroconversion from 12 European countries.

METHODS

Incidence was measured with person-time methods. Generalized estimating equations analysis was used to determine risk factors for STI.

RESULTS

At entry, 15% of the women were diagnosed with at least one acute STI (chlamydial infection, trichomoniasis or gonorrhoea), 10% with at least one other STI (genital warts or genital ulcerations) and 13% with vaginal candidiasis. Although frequently diagnosed during follow-up, the occurrence of acute STI and vaginal candidiasis decreased, whereas the occurrence of other STI increased with ongoing time from HIV infection. Furthermore, women with a history of prostitution [relative risk (RR), 2.00; 95% confidence interval (95% CI), 1.20-3.33] and women with irregular condom use (RR, 7.74; 95% CI, 3.52-17.0) were at higher risk for an acute STI.

CONCLUSIONS

Although STI diagnoses were frequent, the occurrence of acute STI declined with time from infection which might be explained by changed sexual behaviour over time. The occurrence of other STI increased with time from HIV infection, presumably due to reactivation as a result of immunosuppression.

Predictors and risk-taking consequences of drug use among HIV-infected women

OBJECTIVE

To determine rates of drug use among women with HIV, and to examine associations between drug use, health, risk behavior, and sexually transmitted diseases (STD).

DESIGN

A longitudinal cohort study of 260 women with confirmed HIV-positive serostatus.

METHODS

Each participant contributed a self-report interview, a clinical examination, laboratory testing of cultures for Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and urinalysis for the presence of metabolites of cocaine and opiates. Data were examined on 140 women at 1-year follow-up. Women were defined as drug users if they reported crack, cocaine, or heroin use in the 6 months before the interview or if they had a positive toxicologic test result for cocaine or opiates.

RESULTS

34% of those in the sample were classified as positive for drug use. Drug use was associated with the number of sexual partners, age at first intercourse, prevalence of STDs, and lower quality of life. STDs were present at baseline in 33.7% and 15.5% of drug users and nonusers, respectively. Drug use among this population was also associated at both baseline and follow-up with the likelihood of having a Karnofsky score below 80, and with overall perceived general health.

CONCLUSIONS

Drug users in this cohort were more likely to engage in behaviors that place them at risk for STDs, to have elevated STD prevalence, and to have lower perceived health across several indices. Identification of drug use and treatment for it need to be a central component of HIV care for women.

Sexually transmitted infections in women infected with the human immunodeficiency virus. Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA)

BACKGROUND AND OBJECTIVES

Limited prospective data are available on sexually transmitted infections (STIs) among HIV-infected patients. The incidence and predictors of STIs were assessed among HIV-infected women enrolled in a clinical trial.

STUDY DESIGN

Prospective cohort of 323 women.

RESULTS

Sixty-five percent had at least one STI based on history and/or examination at baseline. Most conditions identified at baseline were based on patient history; only 10 of 123 women with no history of an STI (8.1%) had one identified upon examination. During a median follow-up of 2.1 years, 25% developed a new/recurrent STI. Being African-American (odds ratio [OR] = 4.22, 95% confidence interval [CI]: 1.45-12.26), reporting sex with an intravenous drug user as an HIV risk behavior (OR = 2.29, 95% CI: 1.34-3.92), and a history/presence of STIs at baseline (OR = 1.79, 95% CI: 1.01-3.19) were factors associated with significantly increased risk of STI's.

CONCLUSIONS

A substantial proportion of women developed new STIs during the course of the clinical trial. Prevention efforts should be emphasized among high risk HIV-infected patients.

Understanding barriers to condom usage among HIV-infected African American women

Drawing on focus group discussions with adolescent and adult HIV-infected women between the ages of 16 and 45, this study explores the barriers to condom use among women infected with HIV. Although most of the participants were comfortable discussing condoms and sexuality, there was little, if any, negotiation of condom use with their male partners. Most of the participants used condoms inconsistently or not at all. Reasons for nonuse included a lack of trust in the reliability of condoms to protect them, a lack of desire for pregnancy prevention, and the male partner's refusal to use condoms. Women in discordant relationships explained their uninfected partner's refusal to use condoms as denial of the risk of contracting HIV or as a way of expressing their love for the infected partner. Women also had great difficulty in disclosing their HIV status to both family and partners. Prevention efforts to increase condom use among HIV-infected women should target both men and women and focus on negotiation and communication skills.

Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. AIDSCAP Malawi Research Group

BACKGROUND

Transmission of HIV-1 is predominantly by heterosexual contact in sub-Saharan Africa, where sexually transmitted diseases (STDs) are also common. Epidemiological studies suggest that STDs facilitate transmission of HIV-1, but the biological mechanism remains unclear. We investigated the hypothesis that STDs increase the likelihood of transmission of HIV-1 through increased concentration of the virus in semen.

METHODS

HIV-1 RNA concentrations were measured in seminal and blood plasma from 135 HIV-1-seropositive men in Malawi; 86 had urethritis and 49 controls did not have urethritis. Men with urethritis received antibiotic treatment according to the guidelines of the Malawian STD Advisory Committee. Samples were analysed at baseline and at week 1 and week 2 after antibiotic therapy in urethritis patients, and at baseline and week 2 in the control group.

FINDINGS

HIV-1-seropositive men with urethritis had HIV-1 RNA concentrations in seminal plasma eight times higher than those in seropositive men without urethritis (12.4 vs 1.51 x 10(4) copies/mL, p = 0.035), despite similar CD4 counts and concentrations of blood plasma viral RNA. Gonorrhoea was associated with the greatest concentration of HIV-1 in semen (15.8 x 10(4) copies/mL). After the urethritis patients received antimicrobial therapy directed against STDs, the concentration of HIV-1 RNA in semen decreased significantly (from 12.4 x 10(4) copies/mL to 8.91 x 10(4) copies/mL at 1 week [p = 0.03] and 4.12 x 10(4) copies/mL at 2 weeks [p = 0.0001]). Blood plasma viral RNA concentrations did not change. There was no significant change in seminal plasma HIV-1 RNA concentrations during the 2-week period in the control group (p = 0.421).

INTERPRETATION

These results suggest that urethritis increases the infectiousness of men with HIV-1 infection. HIV-1-control programmes, which include detection and treatment of STDs in patients already infected with HIV-1, may help to curb the epidemic. Targeting of gonococcal urethritis may be a particularly effective strategy.