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

Trichomoniasis

Trichomoniasis is the most common nonviral sexually transmitted infection worldwide. It has been associated with a variety of adverse sexual and reproductive health outcomes for both men and women. In this review, the authors discuss updates in its epidemiology, pathophysiology, clinical significance, diagnosis, and treatment.

Diagnosis and Management of Trichomonas vaginalis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

Trichomonas vaginalis is likely the most prevalent nonviral sexually transmitted infection, affecting an estimated 3.7 million women and men in the United States. Health disparities are prominent in the epidemiology of trichomoniasis, as African Americans are >4 times more likely to be infected than persons of other races. Since publication of the 2015 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines, additional data have bolstered the importance of T. vaginalis infection sequelae in women, including increased risk of human immunodeficiency virus (HIV) acquisition, cervical cancer, preterm birth, and other adverse pregnancy outcomes. Less is known about the clinical significance of infection in men. Newly available diagnostic methods, including point-of-care assays and multiple nucleic acid amplification tests, can be performed on a variety of genital specimens in women and men, including urine, allowing more accurate and convenient testing and screening of those at risk for infection. Repeat and persistent infections are common in women; thus, rescreening at 3 months after treatment is recommended. In vitro antibiotic resistance to 5-nitroimidazole in T. vaginalis remains low (4.3%) but should be monitored. High rates of T. vaginalis among sexual partners of infected persons suggest a role for expedited partner treatment. A randomized controlled trial in HIV-uninfected women demonstrated that multidose metronidazole 500 mg twice daily for 7 days reduced the proportion of women with Trichomonas infection at 1 month test of cure compared with women receiving single-dose therapy (2 g). The 2-g single-dose oral metronidazole regimen remains the preferred treatment in men.

A meta-analysis of mannose-binding lectin gene polymorphisms with the risk of recurrent vulvovaginal infections

The genetic variants of Mannose-Binding Lectin, a vital component of innate immunity have been studied with acute/recurrent vaginal infections ((R)VVI) and presented inconclusive findings. Therefore, a systematic review and meta-analysis of published data were conducted to assess the possible role of these variations in (R)VVI. A comprehensive search was made using PubMed, Web of Science and Google scholar till June 18, 2019. A total of 12 studies met the specified criteria and were included in the analysis. Different comparisons were made on the basis of the outcome of interest that resulted in the filtering of studies for the pooled analysis to find an association using the standard genetic models. Odds ratio (OR) with 95% confidence interval (CI) was chosen as the effect measure for the data synthesis. The trim and fill technique was applied to adjust the publication bias. The meta-analysis revealed the significant association (p < 0.05) of rs1800450 polymorphism with RVVI risk (OR ≥ 3.5) in all the genetic models. The subgroup analysis identified the same association in Caucasian and Mixed ethnicity. Quantitative synthesis based on RVVC showed>3.5 fold risk of disease development accredited to rs1800450. A combined evaluation of Exon1 variants showed no association with (R)VVI. This meta-analysis suggests rs1800450 polymorphism as a genetic predisposing factor for RVVI, but to reinforce, further studies with a larger sample size are warranted.

Immunopathology of Recurrent Vulvovaginal Infections: New Aspects and Research Directions

Recurrent vulvovaginal infections (RVVI), a devastating group of mucosal infection, are severely affecting women's quality of life. Our understanding of the vaginal defense mechanisms have broadened recently with studies uncovering the inflammatory nature of bacterial vaginosis, inflammatory responses against novel virulence factors, innate Type 17 cells/IL-17 axis, neutrophils mediated killing of pathogens by a novel mechanism, and oxidative stress during vaginal infections. However, the pathogens have fine mechanisms to subvert or manipulate the host immune responses, hijack them and use them for their own advantage. The odds of hijacking increases, due to impaired immune responses, the net magnitude of which is the result of numerous genetic variations, present in multiple host genes, detailed in this review. Thus, by underlining the role of the host immune responses in disease etiology, modern research has clarified a major hypothesis shift in the pathophilosophy of RVVI. This knowledge can further be used to develop efficient immune-based diagnosis and treatment strategies for this enigmatic disease conditions. As for instance, plasma-derived MBL replacement, adoptive T-cell, and antibody-based therapies have been reported to be safe and efficacious in infectious diseases. Therefore, these emerging immune-therapies could possibly be the future therapeutic options for RVVI.

Incidence and predictors of reinfection with trichomoniasis based on nucleic acid amplification testing results in HIV-infected patients

Trichomonas vaginalis infection contributes to HIV transmission. The study objective was to determine the incidence and predictors of T. vaginalis reinfection among HIV-infected women in Birmingham, Alabama. A retrospective cohort study of women at an urban HIV clinic from August 2014 to March 2016 with T. vaginalis by nucleic acid amplification test (NAAT) was conducted. Time to first episode of reinfection was evaluated using Kaplan-Meier survival curves. The association of various predictors was evaluated by univariate and multivariable Cox proportional hazards analyses. Of 612 HIV-infected women at the UAB HIV clinic tested for T. vaginalis by the Aptima TV assay, 110 (18.0%) were identified with prevalent T. vaginalis infection. Overall, 25/110 (22.7%) had a first episode of T. vaginalis reinfection by NAAT with a rate of 3.7 reinfections per 100 person-months (95% confidence interval [CI]: 2.3, 5.2). In univariate analysis, only an HIV viral load (VL) ≥200 copies/ml approached statistical significance (hazard ratio = 2.26; 95% CI: 0.97, 5.29, p = 0.06). After adjusting for age and race, the association of HIV VL ≥200 copies/ml remained strong (adjusted hazard ratio = 2.49; 95% CI: 0.99, 6.27, p = 0.05). T. vaginalis reinfection was high among HIV-infected women in this sample, necessitating enhanced disease control efforts in this high-risk population.

Factors Affecting Gynecologic and Sexual Assessment in Older Women: A Lesson for Primary Care Providers

Guidelines for screening of cervical cancer and pelvic exams for older women have recently changed. These changes may have unexpected sequelae in women over 65 years of age. This manuscript provides a review of gynecologic screening recommendations for older women in the U.S. and potential ramifications of these recent changes. Peer reviewed guidelines from the American College of Obstetrics and Gynecology, U.S. Preventative Task Force Services, the American Cancer Society, The Centers for Disease Control, and multiple original research articles and reviews were reviewed for this manuscript. Women over 65 are at greatest risk to develop late stage diagnoses of cancers, pelvic organ disease, incontinence, and infections. Clinicians will need to acutely consider this fact when communicating and screening this population. We conclude that practitioners should be aware of the new guidelines and should consider including gynecologic health history and symptom analysis as part of annual exams in women of all ages.

Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues

Trichomonas vaginalis (TV) is likely the most common non-viral sexually transmitted infection (STI) in the world. It is as an important source of reproductive morbidity, a facilitator of HIV transmission and acquisition, and thus it is an important public health problem. Despite its importance in human reproductive health and HIV transmission, it is not a reportable disease and surveillance is not generally done. This is problematic since most persons infected with TV are asymptomatic. Metronidazole (MTZ) has been the treatment of choice for women for decades, and single dose has been considered the first line of therapy. However, high rates of retest positive are found among TV infected persons after single dose MTZ treatment. This has not been explained by drug resistance since in vitro resistance is only 2-5 %. Treatment failure can range from 7-10 % and even higher among HIV+ women. Treatment efficacy may be influenced by vaginal ecology. The origins of repeat positives need further explanation and better treatment options are needed.

Epidemiology and treatment of trichomoniasis

Trichomonas vaginalis is the most common nonviral sexually transmitted infection (STI) in the world. It was once thought to be a nuisance STI, but it is now being recognized as an important source of reproductive morbidity and a facilitator of HIV transmission and acquisition, and thus it is an important public health problem. The prevalence of T. vaginalis varies greatly by geography and risk group, but is more common among persons of African descent and appears to increase with age, though this may be a screening phenomenon. Wet mount and culture are simple diagnostics, but have lower sensitivity than nucleic acid amplification techniques presently approved for women only. Single dose (2 g) metronidazole (MTZ) for both the index patient and their sexual partners is the preferred treatment. High rates of retest positivity are found after single-dose treatment which are likely due to clinical resistance rather than re-infection and/or drug resistance.

The influence of ART on the treatment of Trichomonas vaginalis among HIV-infected women

OBJECTIVE

Among women who are human immunodeficiency virus positive (HIV+), both prevalent and persistent infections with Trichomonas vaginalis (TV) are common. TV has been shown to increase vaginal shedding of HIV, which may influence HIV sexual and perinatal transmission, making prevention important. In 1 cohort of HIV+ women in Kenya, antiretroviral therapy (ART) use, mostly nevirapine based, was associated with lower cure rates of TV for single-dose therapy. Our goal was to repeat this study in a US-based cohort of HIV+/TV+ women and compare outcomes to those with multidose therapy.

METHODS

A secondary data analysis was performed on a multicentered cohort of HIV+/TV+ women who were randomized to single-dose (2 grams) or 7-day (500 mg twice daily) multidose metronidazole (MTZ) treatment. Test of cure visit, via culture, occurred 6-12 days after treatment completion. Information was collected on sex partner treatment and sexual exposures. Persistent TV infection rates were compared for women on ART at baseline vs not on ART.

RESULTS

Of the 226 women included, those on ART had more treatment failures than women not on ART (24/146 [16.4%] vs 5/80 [6.3%]; P = .03). When stratified by treatment arm, more treatment failures were seen in the single-dose arm (17/73 [23.3%] vs 3/39 [7.7%]; P = .05) than in the multidose arm (7/73 [9.6%] vs 2/41 [4.8%]; P = .39).

CONCLUSIONS

ART usage was associated with a higher TV persistent infection rate among those receiving the single-dose treatment, but not the multidose, providing more evidence that multidose should be the preferred treatment for HIV+ women.

A prospective cohort study comparing the effect of single-dose 2 g metronidazole on Trichomonas vaginalis infection in HIV-seropositive versus HIV-seronegative women

BACKGROUND

This analysis compared the frequency of persistent Trichomonas vaginalis (TV) among HIV-seropositive and HIV-seronegative women.

METHODS

Data were obtained from women enrolled in an open cohort study of sex workers in Kenya. Participants were examined monthly, and those diagnosed as having TV by saline microscopy were treated with single-dose 2 g oral metronidazole. All women on antiretroviral therapy (ART) used nevirapine-based regimens. Generalized estimating equations with a logit link were used to compare the frequency of persistent TV (defined as the presence of motile trichomonads by saline microscopy at the next examination visit within 60 days) by HIV status.

RESULTS

Three-hundred sixty participants contributed 570 infections to the analysis (282 HIV-seropositive and 288 HIV-seronegative). There were 42 (15%) persistent infections among HIV-seropositive participants versus 35 (12%) among HIV-seronegative participants (adjusted odds ratio, 1.14; 95% confidence interval [CI], 0.70-1.87). Persistent TV was highest among HIV-seropositive women using ART (21/64 [33%]) compared with HIV-seropositive women not using ART (21/217 [10%]). Concurrent bacterial vaginosis (BV) at TV diagnosis was associated with an increased likelihood of persistent TV (adjusted odds ratio, 1.90; 95% confidence interval, 1.16-3.09).

CONCLUSIONS

The frequency of persistent TV infection after treatment with single-dose 2 g oral metronidazole was similar by HIV status. Alternative regimens including multiday antibiotic treatment may be necessary to improve cure rates for women using nevirapine-based ART and women with TV and concurrent BV.

Genetic diversity of Trichomonas vaginalis reinfection in HIV-positive women

OBJECTIVES

Recently developed genotyping tools allow better understanding of Trichomonas vaginalis population genetics and epidemiology. These tools have yet to be applied to T vaginalis collected from HIV+ populations, where understanding the interaction between the pathogens is of great importance due to the correlation between T vaginalis infection and HIV transmission. The objectives of the study were twofold: first, to compare the genetic diversity and population structure of T vaginalis collected from HIV+ women with parasites from reference populations; second, to use the genetic markers to perform a case study demonstrating the usefulness of these techniques in investigating the mechanisms of repeat infections.

METHODS

Repository T vaginalis samples from a previously described treatment trial were genotyped at 11 microsatellite loci. Estimates of genetic diversity and population structure were determined using standard techniques and compared with previously reported estimates of global populations. Genotyping data were used in conjunction with behavioural data to evaluate mechanisms of repeat infections.

RESULTS

T vaginalis from HIV+ women maintain many of the population genetic characteristics of parasites from global reference populations. Although there is evidence of reduced diversity and bias towards type 1 parasites in the HIV+ population, the populations share a two-type population structure and parasite haplotypes. Genotyping/behavioural data suggest that 36% (12/33) of repeat infections in HIV+ women can be attributed to treatment failure.

CONCLUSIONS

T vaginalis infecting HIV+ women is not genetically distinct from T vaginalis infecting reference populations. Information from genotyping can be valuable for understanding mechanisms of repeat infections.

Trichomoniasis and HIV interactions: a review

OBJECTIVE

To discuss the epidemiology of Trichomonas vaginalis (TV) and HIV co-infections, the role of TV in acquisition and transmission of HIV, special treatment considerations for TV among women with HIV and the prevention of TV among HIV-infected persons.

DESIGN

Systematic review.

DATA SOURCE

Review of literature of EMBASE and PubMed databases from January 1990 to February 2013. Search keywords included TV, HIV co-infections, HIV acquisition, HIV transmission, HIV shedding, TV treatment, HIV and couples studies.

REVIEW METHOD

We included studies of any design that contained the selected search words and were published during the specified time frame. We then searched the reference lists of included papers for additional papers and included these when relevant.

RESULTS

There is strong evidence that TV increases both transmission and acquisition of HIV among women, and that successful treatment for TV can reduce HIV genital shedding. Single dose metronidazole (MTZ) should no longer be used for HIV+ women with TV given the high rates of asymptomatic bacterial vaginosis co-infections and other factors that may render MTZ less effective in HIV+ women. Prevention of TV among HIV+ persons is similar to among HIV, including promotion of condoms as well as regular screening and prompt treatment. There may be a role for expedited partner treatment for the prevention of repeat infections, but most repeat infections are clinical treatment failures. Diligence in screening and treating TV among both HIV- susceptible and HIV+ persons is an important public health strategy.

Trichomonas vaginalis infection among women receiving gynaecological care at an Alabama HIV Clinic

OBJECTIVE

Trichomoniasis vaginalis is a risk factor for the acquisition and transmission of HIV. The objective of this study was to determine the prevalence of T vaginalis (using culture) among HIV-infected women receiving gynaecological care at an university HIV clinic in Alabama in addition to predictors of infection.

METHODS

Electronic medical record review of women presenting to the clinic for gynaecological care during 2006-2012 was performed. Demographic and sexual history data was abstracted in addition to absolute CD4 cell count, HIV-1 viral load and sexually transmitted infection (STI) (including T vaginalis) testing results. Analysis was conducted using Stata V.12.

RESULTS

T vaginalis was prevalent in 17.4% (83/478) of HIV-infected women; other STIs were less prevalent. Among these women, 384 presented for routine STI screening, of which 12% (46/384) were T vaginalis-infected. Younger age, African-American race, lifetime history of tobacco and drug abuse, lack of HIV therapy, HIV-1 viral load >400 copies/ml, and report of seeking gynaecological care for reasons other than routine STI screening (ie, having symptoms) were significant predictors of T vaginalis in univariate analysis. Age, African American race, and report of seeking gynaecological care for reasons other than routine STI screening remained associated with T vaginalis in multivariable analysis.

CONCLUSIONS

T vaginalis remains highly prevalent among HIV-infected women, a proportion of which may be asymptomatic. If left undiagnosed and untreated, these women may be more likely to transmit HIV. Increased emphasis on screening for high risk sexual behaviours, testing for T vaginalis, and risk reduction counselling is necessary for all HIV-infected women.

Patient-delivered partner treatment and Trichomonas vaginalis repeat infection among human immunodeficiency virus-infected women

BACKGROUND

Repeat infections with Trichomonas vaginalis (TV) among human immunodeficiency virus (HIV)-infected women are common and may increase the risk of HIV transmission. Patient delivered partner treatment (PDPT) has been shown to reduce repeat infections of other sexually transmitted diseases. The purpose of this study was to evaluate adherence to PDPT and possible causes of repeat TV infection among HIV-infected women.

METHODS

A multicentered cohort study was conducted in 3 US cities. Women coinfected with HIV and TV were treated with metronidazole and given treatment to deliver to all reported sex partners. A test-of-cure visit was conducted 6 to 12 days post index treatment completion and behavioral data were collected.

RESULTS

Of 252 women (mean age = 40 years, s.d. 9.1) enrolled, 92.5% were black, 26.2% had CD4 cell counts <200/mm(3), 34.1% had plasma viral loads >10,000 copies, 58.3% were taking antiretrovial therapy, and 15.1% had multiple partners. Of the 183 women with partners at baseline, 75.4% provided PDPT to all partners and 61.7% reported they were sure all of their partners took the medication. Factors associated with not giving medications to all partner(s) were multiple sex partners, being single, and having at least one partner unaware of the index woman's HIV status. At test-of-cure, 10.3% were TV-positive and 16.7% reported having sex since baseline. Of the 24 repeat infections, 21 (87.5%) reported adherence to medication and no sexual exposure.

CONCLUSION

HIV-infected women with TV reported high adherence to PDPT, and treatment failure was the most common probable cause of repeat infection.

Trichomonas vaginalis screening and prevention in order to impact the HIV pandemic: Isn't it time we take this infection seriously?

Trichomonas vaginalis (TV) is the second most common sexually transmitted infection (STI) in the world. It is associated with significant morbidity in women: pelvic inflammatory disease (PID), concurrent vaginitis and sexually transmitted infections (STIs), post-operative infection, and pregnancy complications. TV infection has been implicated in HIV acquisition and transmission in men and women. There are multiple mechanisms to explain this association. TV is not routinely screened for in asymptomatic patients; however, infected individuals are most often asymptomatic. Due to the association with the spread of HIV infection, screening should not be limited to symptomatic patients or those seeking treatment for STIs. There are a variety of tests available to detect TV. Treatment of TV has demonstrated lower rates of HIV acquisition in at risk women. In HIV positive men and women, treatment decreases the amount of genital HIV shedding and subsequent infectivity. Initiation of an effective TV screening and treatment program in HIV positive and HIV susceptible populations may limit further transmission of HIV.

Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention

Sexually transmitted co-infections increase HIV infectiousness through local inflammatory processes. The prevalence of STI among people living with HIV/AIDS has implications for containing the spread of HIV in general and the effectiveness of HIV treatments for prevention in particular. Here we report a systematic review of STI co-infections in people living with HIV/AIDS. We focus on STI contracted after becoming HIV infected. Electronic database and manual searches located 37 clinical and epidemiological studies of STI that increase HIV infectiousness. Studies of adults living with HIV/AIDS from developed and developing countries reported STI rates for 46 different samples (33 samples had clinical/laboratory confirmed STI). The overall mean point-prevalence for confirmed STI was 16.3% (SD=16.4), and median 12.4% STI prevalence in people living with HIV/AIDS. The most common STI studied were Syphilis with median 9.5% prevalence, Gonorrhea 9.5%, Chlamydia 5%, and Trichamoniasis 18.8% prevalence. STI prevalence was greatest at the time of HIV diagnosis, reflecting the role of STI in HIV transmission. Prevalence of STI among individuals receiving HIV treatment was not appreciably different from untreated persons. The prevalence of STI in people infected with HIV suggests that STI co-infections could undermine efforts to use HIV treatments for prevention by increasing genital secretion infectiousness.

The influence of bacterial vaginosis on the response to Trichomonas vaginalis treatment among HIV-infected women

OBJECTIVE

Trichomonas vaginalis (TV) is common in HIV+ women, and host factors may play a role in TV treatment outcomes. The purpose of this study was to examine the influence of bacterial vaginosis (BV) on the response to TV treatment among HIV+ women.

METHODS

A secondary analysis was conducted of a clinical trial which randomised HIV+/TV+ women to metronidazole (MTZ) treatment: 2 g (single-dose) versus 7 day 500 mg twice daily (multidose). BV was classified using Nugent scores from baseline Gram stains. Women were recultured for TV at test-of-cure (TOC) and again at 3 months if TV-negative at TOC. Repeat TV infection rates were compared for women with a baseline TV/BV coinfection versus baseline TV infection only, and stratified by treatment arm.

RESULTS

Among 244 HIV+/TV+ women (mean age=40.3, ±9.5; 92.2% African-American), the rate of BV was 66.8%. Women with BV were more likely to report douching and ≥1 recent sex partners. HIV+ women with baseline TV/BV coinfection were more likely to be TV-positive at TOC than women with baseline TV infection only (RR 2.42 (95% CI 0.96 to 6.07; p=0.05)). When stratified by treatment arm, the association was only found in the single-dose arm (p=0.02) and not in the multidose arm (p=0.92). This interaction did not persist at 3 months.

CONCLUSIONS

For HIV+/TV+ women, the rate of BV was high, and BV was associated with early failure of the MTZ single-dose treatment for TV. Biological explanations require further investigation.

A randomized treatment trial: single versus 7-day dose of metronidazole for the treatment of Trichomonas vaginalis among HIV-infected women

OBJECTIVE

To determine if the metronidazole (MTZ) 2-gm single dose (recommended) is as effective as the 7-day 500 mg twice a day dose (alternative) for treatment of Trichomonas vaginalis (TV) among HIV+ women.

METHODS

Phase IV randomized clinical trial; HIV+ women with culture confirmed TV were randomized to treatment arm: MTZ 2-gm single dose or MTZ 500 mg twice a day 7-day dose. All women were given 2-gm MTZ doses to deliver to their sex partners. Women were recultured for TV at a test-of-cure (TOC) visit occurring 6-12 days after treatment completion. TV-negative women at TOC were again recultured at a 3-month visit. Repeat TV infection rates were compared between arms.

RESULTS

Two hundred seventy HIV+/TV+ women were enrolled (mean age = 40 years, ±9.4; 92.2% African American). Treatment arms were similar with respect to age, race, CD4 count, viral load, antiretroviral therapy status, site, and loss-to-follow up. Women in the 7-day arm had lower repeat TV infection rates at TOC [8.5% (11 of 130) versus 16.8% (21 of 125) (relative risk: 0.50, 95% confidence interval = 0.25, 1.00; P < 0.05)] and at 3 months [11.0% (8 of 73) versus 24.1% (19 of 79) (relative risk: 0.46, 95% confidence interval = 0.21, 0.98; P = 0.03)] compared with the single-dose arm.

CONCLUSIONS

The 7-day MTZ dose was more effective than the single dose for the treatment of TV among HIV+ women.

Current issues and considerations regarding trichomoniasis and human immunodeficiency virus in African-Americans

Trichomonas vaginalis has long been recognized as one of the most prevalent sexually transmitted infections. However, it is only in recent years that it has been appreciated that Trichomonas may play a critical role in amplifying human immunodeficiency virus (HIV) transmission. Given the evidence that T. vaginalis likely promotes HIV infection, the apparent high level of Trichomonas infection in the African-American community is cause for concern. Even if T. vaginalis increases the risk of HIV transmission by a small or modest amount, it translates into a sizable population effect since Trichomonas is so common in this community. Therefore, control of trichomoniasis may represent an important avenue of control for the prevention of HIV transmission, particularly among African-Americans.

Trichomonas vaginalis treatment reduces vaginal HIV-1 shedding

BACKGROUND

Vaginal HIV-1 shedding has been associated with Trichomonas vaginalis (TV) infection and could play a role in HIV transmission. The purpose of the study was to examine if effective TV treatment reduces the presence of vaginal HIV-1 RNA.

METHODS

TV+ women attending an HIV outpatient clinic in New Orleans, LA, who resolved infection (n = 58) and TV-negative controls (n = 92), matched on antiretroviral therapy (ART) were examined and interviewed at baseline, 1, and 3 months. TV status was tested by culture and the amount of cell free HIV-1 RNA in the vaginal fluids was determined by the Amplicor HIV-1 Monitor ultrasensitive assay.

RESULTS

: Most women (81.3%) were black and the mean age was 37.5 (SD 8.7). At baseline, 46.0% had plasma HIV-1 RNA >/=10,000 copies/mL, 26.4% had CD4<200 cells/muL, 54.7% were taking ART, and only 26.0% had detectable HIV-1 RNA in their vaginal fluids. TV-positive women who were effectively treated for TV were less likely to shed HIV vaginally at 3-months post-treatment compared to baseline (R.R. 0.34, 95% CI: 0.12-0.92, P = 0.03), whereas there was no change for TV-negative women.

CONCLUSION

This study provides additional support that reducing TV infection among HIV-positive women may have an impact on the prevention of HIV transmission. Reasons for the delayed treatment effect and the effect on cervical shedding need further investigation.

Factors associated with the prevalence and incidence of Trichomonas vaginalis infection among African American women in New York city who use drugs

BACKGROUND

Trichomoniasis vaginalis, the most prevalent nonviral sexually transmitted infection, is associated with negative reproductive outcomes and increased HIV transmission and may be overrepresented among African Americans.

METHODS

A total of 135 African American women who used drugs were screened for Trichomonas vaginalis on > or =2 occasions between March 2003 and August 2005. Women were administered a structured questionnaire in a community-based research center, underwent serological testing for human immunodeficiency virus and herpes simplex virus type 2, and were screened for Neisseria gonorrhoeae and Chlamydia trachomatis.

RESULTS

Fifty-one women (38%) screened positive for T. vaginalis at baseline. Twenty-nine (31%) of 95 women with negative results of baseline tests became infected, for an incidence of 35.1 cases per 100 person-years at risk (95% confidence interval [CI], 23.5-49.0). Prevalent infection was associated with drug use in the past 30 days, and incident infection was associated with sexual behavior in the past 30 days, namely having >1 male sex partner. Women who reported having >1 partner were 4 times as likely as women with fewer partners to acquire T. vaginalis (hazard ratio, 4.3; 95% CI, 2.0-9.4).

CONCLUSION

T. vaginalis may be endemic in this community of African American women. A control strategy that includes T. vaginalis screening in nonclinical settings and rapid point-of-care testing could contribute to the disruption of transmission of this pathogen.

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.

Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial

OBJECTIVES

Infections with Trichomonas vaginalis (TV) are common and recurrence rates are high. Better methods of treating partners of women with trichomoniasis are needed.

GOAL

To determine if patient-delivered partner treatment (PDPT) is better and more cost-effective than partner referral.

STUDY DESIGN

Women attending a family planning clinic who were culture-positive and treated for TV (N = 463) were randomized to either standard partner referral (PR), booklet-enhanced partner referral (BEPR), or PDPT. At baseline and 1 month, women were interviewed and cultured for TV. Detailed cost information was also collected.

RESULTS

Most women had 1 partner, were less than 24 years old, and were black. The percentage of women reporting that their partners were treated was similar for PDPT but significantly lower for BEPR compared to PR. TV follow-up rates were similar. PDPT cost less and was cost saving compared to PR and BEPR.

CONCLUSION

Among women with TV, PDPT did not result in more partners taking the medicine or lower follow-up rates than PR but was less costly.

Trichomoniasis

Trichomoniasis is perhaps the most common curable sexually transmitted disease worldwide, yet few resources are devoted to its control. It is associated with potentially serious complications such as preterm birth and human immunodeficiency virus acquisition and transmission. The immunology of a related organism, Tritrichomonas foetus, which causes disease in cattle, has been investigated to some extent, but more work is needed for the human strain, Trichomonas vaginalis. In addition, although trichomoniasis is easily treated with oral metronidazole, there is concern that the number of strains resistant to this antibiotic are increasing, and currently no alternative is licensed in the United States. As more is appreciated concerning the important public health implications of this common infection, more work will need to be done in understanding the diagnosis, treatment, and immunology of this organism.

Women and human immunodeficiency virus: unique management issues

Women currently account for an increasing proportion of the US population infected with human immunodeficiency virus (HIV). Although women suffer from similar HIV-related complications as men, they also can have unique gynecologic manifestations, such as cervical dysplasia or severe pelvic inflammatory disease. Other gender-specific management issues include contraception and pregnancy. Fortunately, today the perinatal HIV transmission rate can be lowered to less than 2% with appropriate management. More couples, including those discordant for HIV infection, are opting to pursue conception. Providers caring for HIV-infected women should be knowledgeable about reproductive choices, including the full array of available options. Strategies shown to improve access of health care to HIV-infected women include integrating gynecologic services with primary care, daily availability of medical services, provision of transportation, and provision of on-site childcare.

Trichomoniasis: clinical manifestations, diagnosis and management

Trichomonas vaginalis was originally considered a commensal organism until the 1950s when the understanding of its role as a sexually transmitted infection (STI) began to evolve. Trichomoniasis has been associated with vaginitis, cervicitis, urethritis, pelvic inflammatory disease (PID), and adverse birth outcomes. Infection with T vaginalis could have an important role in transmission and acquisition of HIV. T vaginalis is site specific for the genitourinary tract and has been isolated from virtually all genitourinary structures. Asymptomatic disease is common in both men and women, thus screening for disease is important. Various sociodemographic factors have been correlated with presence of T vaginalis, and may be used to predict infection. Diagnosis is usually made from wet mount microscopy and direct visualisation, which are insensitive. DNA amplification techniques perform with good sensitivity, but are not yet approved for diagnostic purposes. In areas where diagnostic methods are limited, management of trichomoniasis is usually as part of a clinical syndrome; vaginal discharge for women and urethral discharge for men. A single dose of metronidazole is effective in the majority of cases. Outside of the United States, other nitroimidazoles may be used and are as effective as metronidazole. Metronidazole resistance is an emerging problem, but its clinical importance is not yet clear. Concomitant treatment of sexual partners is recommended.

Trichomonas vaginalis Among HIV-Infected Women

BACKGROUND AND OBJECTIVES

Trichomonas vaginalis (Tv) is a common sexually transmitted disease (STD) among HIV-infected populations. The relationship between Tv and immune status and HIV viral load as affected by protease inhibitor (PI) use has not been well examined.

GOAL

The goals were to evaluate the association between Tv and both immune status and PI use among HIV-infected women, and to characterize factors associated with Tv among HIV-infected women.

STUDY DESIGN

We used a retrospective cohort study conducted between 1990 and 2000.

RESULTS

Of 1578 women, the majority was under 35 years, black (AA), and infected heterosexually or with unidentified risk. Thirty percent (30.2%) had Tv at least once, and 36.9% had at least one subsequent positive test; Tv was more common than chlamydia, gonorrhea, genital warts, or syphilis. After adjusting for follow-up time, young age, AA race, substance use, and other sexually transmitted diseases (STDs) were associated with initial Tv infection, but pregnancy, immune status, and PI use were not associated. After adjusting for follow-up time, having other STDs was associated with and pregnancy was protective of subsequent Tv positivity, but immune status and PI use were not associated; neither were age, race, or substance use.

CONCLUSION

Tv is a common STD among HIV-infected women and does not appear to be associated with immune status or PI use. Aggressive screening might represent a means of reducing the incidence and prevalence of Tv.

Trichomonas vaginalis, HIV, and African-Americans

Trichomonas vaginalis may be emerging as one of the most important cofactors in amplifying HIV transmission, particularly in African-American communities of the United States. In a person co-infected with HIV, the pathology induced by T. vaginalis infection can increase HIV shedding. Trichomonas infection may also act to expand the portal of entry for HIV in an HIV-negative person. Studies from Africa have suggested that T. vaginalis infection may increase the rate of HIV transmission by approximately twofold. Available data indicate that T. vaginalis is highly prevalent among African-Americans in major urban centers of the United States and is often the most common sexually transmitted infection in black women. Even if T. vaginalis increases the risk of HIV transmission by a small amount, this could translate into an important amplifying effect since Trichomonas is so common. Substantial HIV transmission may be attributable to T. vaginalis in African-American communities of the United States.

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.