Chlamydial and gonococcal cervicitis in HIV-seropositive and HIV-seronegative pregnant women in Bangkok: prevalence, risk factors, and relation to perinatal HIV transmission

The initial interplay between HIV and mucosal innate immunity

Human Immunodeficiency Virus (HIV) is still one of the major global health issues, and despite significant efforts that have been put into studying the pathogenesis of HIV infection, several aspects need to be clarified, including how innate immunity acts in different anatomical compartments. Given the nature of HIV as a sexually transmitted disease, one of the aspects that demands particular attention is the mucosal innate immune response. Given this scenario, we focused our attention on the interplay between HIV and mucosal innate response: the different mucosae act as a physical barrier, whose integrity can be compromised by the infection, and the virus-cell interaction induces the innate immune response. In addition, we explored the role of the mucosal microbiota in facilitating or preventing HIV infection and highlighted how its changes could influence the development of several opportunistic infections. Although recent progress, a proper characterization of mucosal innate immune response and microbiota is still missing, and further studies are needed to understand how they can be helpful for the formulation of an effective vaccine.

Minimizing the Risk of Perinatal Human Immunodeficiency Virus Transmission

Importance

There are approximately 284,500 adolescent and adult women living with human immunodeficiency virus (HIV) in the United States. It is estimated that approximately 8500 of these women give birth annually. While the rate of perinatal transmission in the United States has decreased by more than 90% since the early 1990s, potentially preventable HIV transmission events still occur and cause significant morbidity and mortality.

Objective

The aim of this review was to summarize the current data regarding perinatal HIV transmission timing and risk factors, current management recommendations, and implications of timing of transmission on patient management.

Evidence Acquisition

Literature review.

Results

This review reiterates that the risk of perinatal HIV transmission can be reduced to very low levels by following current recommendations for screening for HIV in all pregnant women and properly treating HIV-infected mothers, as well as using evidence-based labor management practices.

Conclusions and Relevance

Familiarity with the pathogenesis of HIV transmission is important for obstetric care providers to appropriately manage HIV-infected women in pregnancy, intrapartum, and the postpartum period.

Women infected with HIV and the impact of associated sexually transmitted infections

OBJECTIVE

To review the relationship between concomitant sexually transmitted infections in women infected with HIV.

METHODS

PubMed and Scopus were searched for articles published in English and Portuguese between January 1, 1994, and December 31, 2015, using relevant keywords, including AIDS, HIV, female genital diseases, and sexually transmitted infections. Articles that associated sexually transmitted infections with HIV-infected women were selected for inclusion. Those that only investigated prevalence in pregnant women or focused on social or behavioral aspects were excluded.

RESULTS

Of 108 identified articles, 24 were included. When correlated with HIV, genital herpes demonstrated an increased recurrence rate and increased replication rate for HIV in the mucosa. In HIV-positive women, syphilis can cause more genital ulcers. Bacterial vaginosis provides a pool of microorganisms that can increase the viral copy levels of genital HIV. Chlamydia, gonorrhea, and candidiasis may be more severe and complicated in women infected with HIV.

CONCLUSIONS

Screening of HIV-positive patients who could have other sexually transmitted infections is important to protect women and decrease the risk of transmission.

Combined evaluation of sexually transmitted infections in HIV-infected pregnant women and infant HIV transmission

Background

Sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and cytomegalovirus (CMV) may lead to adverse pregnancy and infant outcomes. The role of combined maternal STIs in HIV mother-to-child transmission (MTCT) was evaluated in mother-infant pairs from NICHD HPTN 040.

Methodology

Urine samples from HIV-infected pregnant women during labor were tested by polymerase chain reaction (PCR) for CT, NG, and CMV. Infant HIV infection was determined by serial HIV DNA PCR testing. Maternal syphilis was tested by VDRL and confirmatory treponemal antibodies.

Results

A total of 899 mother-infant pairs were evaluated. Over 30% had at least one of the following infections (TP, CT, NG, and/or CMV) detected at the time of delivery. High rates of TP (8.7%), CT (17.8%), NG (4%), and CMV (6.3%) were observed. HIV MTCT was 9.1% (n = 82 infants). HIV MTCT was 12.5%, 10.3%, 11.1%, and 26.3% among infants born to women with CT, TP, NG or CMV respectively. Forty-two percent of HIV-infected infants were born to women with at least one of these 4 infections. Women with these infections were nearly twice as likely to have an HIV-infected infant (aOR 1.9, 95% CI 1.1–3.0), particularly those with 2 STIs (aOR 3.4, 95% CI 1.5–7.7). Individually, maternal CMV (aOR 4.4 1.5–13.0) and infant congenital CMV (OR 4.1, 95% CI 2.2–7.8) but not other STIs (TP, CT, or NG) were associated with an increased risk of HIV MTCT.

Conclusion

HIV-infected pregnant women identified during labor are at high risk for STIs. Co-infection with STIs including CMV nearly doubles HIV MTCT risk. CMV infection appears to confer the largest risk of HIV MTCT.

Trial registration

NCT00099359.

Chlamydia and Gonorrhea in HIV-Infected Pregnant Women and Infant HIV Transmission

BACKGROUND

Sexually transmitted infections (STIs) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) can lead to adverse pregnancy and neonatal outcomes. The prevalence of STIs and its association with HIV mother-to-child transmission (MTCT) were evaluated in a substudy analysis from a randomized, multicenter clinical trial.

METHODOLOGY

Urine samples from HIV-infected pregnant women collected at the time of labor and delivery were tested using polymerase chain reaction testing for the detection of CT and NG (Xpert CT/NG; Cepheid, Sunnyvale, CA). Infant HIV infection was determined by HIV DNA polymerase chain reaction at 3 months.

RESULTS

Of the 1373 urine specimens, 249 (18.1%) were positive for CT and 63 (4.6%) for NG; 35 (2.5%) had both CT and NG detected. Among 117 cases of HIV MTCT (8.5% transmission), the lowest transmission rate occurred among infants born to CT- and NG-uninfected mothers (8.1%) as compared with those infected with only CT (10.7%) and both CT and NG (14.3%; P = 0.04). Infants born to CT-infected mothers had almost a 1.5-fold increased risk for HIV acquisition (odds ratio, 1.47; 95% confidence interval, 0.9-2.3; P = 0.09).

CONCLUSIONS

This cohort of HIV-infected pregnant women is at high risk for infection with CT and NG. Analysis suggests that STIs may predispose to an increased HIV MTCT risk in this high-risk cohort of HIV-infected women.

Chlamydia trachomatis Infection in Pregnancy: The Global Challenge of Preventing Adverse Pregnancy and Infant Outcomes in Sub-Saharan Africa and Asia

Screening and treatment of sexually transmitted infections (STIs) in pregnancy represents an overlooked opportunity to improve the health outcomes of women and infants worldwide. Although Chlamydia trachomatis is the most common treatable bacterial STI, few countries have routine pregnancy screening and treatment programs. We reviewed the current literature surrounding Chlamydia trachomatis in pregnancy, particularly focusing on countries in sub-Saharan Africa and Asia. We discuss possible chlamydial adverse pregnancy and infant health outcomes (miscarriage, stillbirth, ectopic pregnancy, preterm birth, neonatal conjunctivitis, neonatal pneumonia, and other potential effects including HIV perinatal transmission) and review studies of chlamydial screening and treatment in pregnancy, while simultaneously highlighting research from resource-limited countries in sub-Saharan Africa and Asia.

Clinical focus: infections in pregnancy

Pregnant women are particularly susceptible to a number of infectious diseases, such as influenza, hepatitis E, malaria, and tuberculosis. The management of many other infections-including urinary tract infections, human immunodeficiency virus, and sexually transmitted diseases-is also made more complex by pregnancy; even if some infections do not pose a great risk to the expectant mother, they can impact fetal and neonatal development, thus posing a treatment challenge to physicians. By focusing on the most important diseases that physicians may encounter in pregnant patients, this review outlines the challenges associated with managing important infectious diseases in the pregnant population and references the most recent evidence and international treatment guidelines.

Sexually transmitted infections among HIV-infected women in Thailand

Background

Data on sexually transmitted infections (STI) prevalence among HIV-infected women in Thailand are limited. We studied, among HIV-infected women, prevalence of STI symptoms and signs; prevalence and correlates of having any STI; prevalence and correlates of Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (GC) among women without CT and/or GC symptoms or signs; and number of women without CT and/or GC symptoms or signs needed to screen (NNS) to detect one woman with CT and/or GC overall, among pregnant women, and among women ≤25 years.

Methods

During October 2004–September 2006, HIV-infected women at 3 obstetrics and gynecology clinics were asked about sexual behaviors and STI symptoms, physically examined, and screened for chlamydia, gonorrhea, trichomoniasis, and syphilis. Multivariate logistic regression was used to identify correlates of infections. NNS was calculated using standard methods.

Results

Among 1,124 women, 526 (47.0%) had STI symptoms or signs, 469 (41.7%) had CT and/or GC symptoms or signs, and 133 (11.8%) had an STI. Correlates of having an STI included pregnancy and having STI signs. Among 469 women and 655 women with vs. without CT and/or GC symptoms or signs, respectively, 43 (9.2%) vs. 31 (4.7%), 2 (0.4%) vs. 9 (1.4%), and 45 (9.6%) vs. 38 (5.8%) had CT, GC, or “CT or GC”, respectively; correlates included receiving care at university hospitals and having sex with a casual partner within 3 months. NNS for women overall and women ≤25 years old were 18 (95% CI, 13-25) and 11 (95% CI, 6-23), respectively; and for pregnant and non-pregnant women, 8 (95% CI, 4-24) and 19 (95% CI, 14-27), respectively.

Conclusions

STI prevalence among HIV-infected women, including CT and GC among those without symptoms or signs, was substantial. Screening for CT and GC, particularly for pregnant women, should be considered.

Gynaecological morbidity among HIV positive pregnant women in Cameroon

OBJECTIVE

To compare the prevalence of gynaecological conditions among HIV infected and non-infected pregnant women.

METHODS

Two thousand and eight (2008) pregnant women were screened for HIV, lower genital tract infections and lower genital tract neoplasia at booking antenatal visit.

RESULTS

About 10% (198/2008) were HIV positive. All lower genital tract infections except candidiasis were more prevalent among HIV positive compared to HIV negative women: vaginal candidiasis (36.9% vs 35.4%; p = 0.678), Trichomoniasis (21.2% vs 10.6%; p < 0.001), gonorrhoea (10.1% vs 2.5%; p < 0.001), bacterial vaginosis (21.2% vs 15.2%; p = 0.026), syphilis (35.9% vs 10.6%; p < 0.001), and Chlamydia trachomatis (38.4% vs 7.1%; p < 0.001). Similarly, HIV positive women more likely to have preinvasive cervical lesions: low-grade squamous intraepithelial lesion (SIL) (18.2% vs 4.4%; p < 0.001) and high-grade squamous intraepithelial lesion (12.1% vs 1.5%; p < 0.001).

CONCLUSION

We conclude that (i) sexually transmitted infections (STIs) are common in both HIV positive and HIV negative pregnant women in Cameroon, and (ii) STIs and preinvasive cervical lesions are more prevalent in HIV-infected pregnant women compared to their non-infected compatriots. We recommend routine screening and treatment of STIs during antenatal care in Cameroon and other countries with similar social profiles.

Prevalence of Chlamydia trachomatis in human immunodeficiency virus-infected women in Cuba

To determine the prevalence rates and serovar distribution of Chlamydia trachomatis cervical infections in Cuban women, two different groups were selected. Group I consisted of 60 human immunodeficiency virus (HIV-1) seropositive women from different regions of Cuba and group II of 60 randomly selected women HIV seronegative and apparently healthy. C. trachomatis was detected in cervical scrapes by mean of nested polymerase chain reaction (PCR) specific for major out membrane protein. The overall prevalence rate of C. trachomatis in cervical scrapes determined by nested PCR was 10% in group I and the estimated prevalence was 6.6% for group II; 83.3% of HIV seropositive women with C. trachomatis infection reported history of pelvic inflammatory disease followed by cervicitis (50%). The control group C. trachomatis-infected women referred a history of cervicitis in 75% of cases. Other reports in the latter group included infertility and pelvic inflamatory disease in 50%. The present study is the first report of C. trachomatis prevalence in Cuba. It showed that there was not significantly difference in the prevalence rate of C. trachomatis between both groups.

Rapid assessment of sexual behavior, drug use, human immunodeficiency virus, and sexually transmitted diseases in northern thai youth using audio-computer-assisted self-interviewing and noninvasive specimen collection

BACKGROUND

Drug use, unwanted pregnancy, human immunodeficiency virus (HIV) infection, and sexually transmitted diseases are serious health problems among Thai youth. The gravity of these problems demands high-quality data to direct public health policy and prevention programs. Previous studies of stigmatized behaviors have been hampered by participation bias and underreporting. To evaluate sexual behavior, disease, and drug use, we used audio-computer-assisted self-interviewing (ACASI) and noninvasive specimen collection methods. We also evaluated effectiveness of these methods in minimizing participation bias and underreporting.

METHODS

In late 1999, students aged 15 to 21 years attending 3 vocational schools were invited to participate in a cross-sectional survey. Consenting students completed a classroom-based ACASI interview using a confidential code number system. Oral fluid specimens were tested for HIV antibodies, and urine was tested for chlamydial and gonococcal nucleic acids, methamphetamines, and opiates.

RESULTS

Of 1736 invited students, 1725 (99%) agreed to participate. Of these, 48% of the male students and 43% of the female students reported ever having had sexual intercourse. Overall, the mean number of lifetime sexual partners was 4.6 among male participants (median: 2) and 2.8 among female participants (median: 1). Consistent use of condoms with steady partners was reported by 16% of male participants and 11% of female participants who had such partners. Of all male participants, 7% had ever paid for sex, 3% had ever sold sex, and 7% had ever been coerced to have sex. Of all female participants, 3% had ever sold sex and 21% had ever been coerced to have sex. Among women with a history of sexual intercourse, 27% reported at least 1 pregnancy. Of these pregnancies, 83% were terminated. Among those with sexual intercourse experience, the prevalence of HIV infection was 0.5%; of infection with Neisseria gonorrhoeae, 0.4%; and of infection with Chlamydia trachomatis, 5%. Twenty-nine percent of students reported ever having used methamphetamines. Ten percent had a methamphetamine-positive urine test. In the ACASI interview, 16% of these denied ever having used methamphetamines. The prevalence of opiate positive urine tests was low (0.2%).

CONCLUSION

This study shows that adolescents and young adults in Chiang Rai are at high risk for having unprotected intercourse, being coerced to have sex, unwanted pregnancy, sexually transmitted diseases, and drug use. The high enrollment rate demonstrates the feasibility and acceptability of using ACASI and noninvasive specimen collection methods in a developing country. ACASI use may lead to increased, but not to complete, self-reporting of sensitive behaviors.

Screening for sexually transmitted diseases in human immunodeficiency virus-positive patients in Peru reveals an absence of Chlamydia trachomatis and identifies Trichomonas vaginalis in pharyngeal specimens

To determine the prevalence of sexually transmitted diseases (STDs), we screened 107 human immunodeficiency virus-positive patients in Peru, where the virus is predominantly sexually transmitted. Patients had multiple risk factors for STDs, and 38% of women and 50% of men had at least 1 STD (gonorrhea, trichomoniasis, herpes simplex, anogenital warts, or syphilis seropositivity). No chlamydial infection was detected, even though infection rates in the general population are 5%-12%. Patients receiving trimethoprim-sulfamethoxazole(TMP-SMZ) for prophylaxis or treatment of respiratory infections were least likely to have cervicitis and/or urethritis (odds ratio, 0.37; 95% confidence interval, 0.15-0.89). Although not optimal treatment, administration of TMP-SMZ is effective against chlamydial infection. We speculate that the use of concomitant medications, such as TMP-SMZ, may be inadvertently preventing chlamydial infection in this population. Another finding was the presence of Trichomonas vaginalis in pharyngeal specimens of 3 men with histories of orogenital activity. This has not been previously reported and requires further study.

Gynecologic infections in human immunodeficiency virus-infected women

The maturation of the acquired immunodeficiency syndrome epidemic has now claimed more than 12 million women worldwide, the majority in undeveloped countries where human immunodeficiency virus (HIV) and sexually transmitted infections coexist and interact synergistically. Among HIV-infected women, there is excessive morbidity due to sexually transmitted diseases (STDs) and gynecologic disorders. This review summarizes the expanding understanding of vaginal flora, vaginitis, cervicitis, pelvic inflammatory disease, and genital ulcer disease in HIV-infected women. In addition to the altered clinical course, complications, and management difficulties of STDs, some gynecologic infections may influence HIV transmission as well as the vertical transmission of HIV to the newborn. Finally, severe immunodeficiency allows unusual opportunistic pathogens to invade the upper and lower genital tract. Control and prevention of gynecologic infections in HIV-positive and HIV-negative women are key components to preventing further HIV transmission.

Behavioural and serological human immunodeficiency virus risk factors among female commercial sex workers in Cambodia

BACKGROUND

The spread of human immunodeficiency virus (HIV) in Cambodia is mainly caused by sexual transmission and the high-risk group in this country are female commercial sex workers (CSW). There are two types of CSW, direct CSW (DCSW) and indirect CSW (IDCSW), who are different from each other in sexual activities. This study was conducted in order to describe the risk factors on HIV for each type of CSW, and to establish effective preventive strategies against the HIV epidemic among CSW.

METHODS

The participants, 143 DCSW and 94 IDCSW, were interviewed using a questionnaire to determine their demographic characteristics and behaviour. Blood samples were taken for serological tests on HIV, Chlamydia trachomatis and syphilis. The association between their behavioural pattern and their serological results was analysed.

RESULTS

The questionnaire study showed that IDCSW had a riskier behavioural pattern than DCSW. The HIV seroprevalence rates of the DCSW and the IDCSW were 52.4% and 22.3%, respectively. Univariate logistic analyses showed a significant association between HIV antibody (HIV-Ab) and current age, age at commencement of commercial sex work, duration of commercial sex work, and the seropositivity of Chlamydia trachomatis-IgG antibody (CT-IgG-Ab) among the DCSW. The analyses also showed a significant relationship between HIV-Ab and CT-IgG-Ab among the IDCSW.

CONCLUSIONS

Improving condom use rate is very important in order to prevent an HIV epidemic among the two types of CSW. This study also suggests it is important to prevent sexually transmitted disease (STD) such as Chlamydia trachomatis infection. The STD control programme could be efficient for HIV prevention, especially among DCSW.

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.

Rapid assessment of sexually transmitted diseases in a sentinel population in Thailand: prevalence of chlamydial infection, gonorrhoea, and syphilis among pregnant women--1996

OBJECTIVE

To determine the prevalence of sexually transmitted diseases (STDs) among pregnant women in Thailand, where case reporting suggests a marked decrease in STDs following a campaign promoting condom use during commercial sex.

DESIGN

Cross sectional study of women at their first visit to the study hospitals' antenatal clinics in Chiang Rai (n = 500) and Bangkok (n = 521).

METHODS

First catch urine specimens were tested for Chlamydia trachomatis and Neisseria gonorrhoeae using the Amplicor CT/NG polymerase chain reaction assay. Syphilis and HIV serological testing were performed in the study hospitals' laboratories.

RESULTS

The prevalence of chlamydial infection was 5.7%, gonorrhoea 0.2%, and syphilis 0.5% (all VDRL or RPR titres were < or = 1:4). The prevalence of HIV infection was 7.1% in Chiang Rai and 2.9% in Bangkok. In a multivariate logistic regression analysis, chlamydial infection was associated with younger age and with higher gestational age at first antenatal clinic visit, but was not associated with marital status, gravidity, city of enrollment, or HIV infection status.

CONCLUSIONS

There was a low prevalence of gonorrhoea and syphilis among these pregnant women in Thailand. Chlamydial infection was detected at a higher prevalence, especially among younger women and women registering later for antenatal care. Testing of pregnant women using easily collected urine specimens and a sensitive nucleic acid amplification assay is a feasible method of rapidly assessing chlamydial and gonococcal prevalence.