Detection of Y chromosome DNA as evidence of semen in cervicovaginal secretions of sexually active women

Screening and characterization of vaginal fluid donations for vaginal microbiota transplantation

Bacterial vaginosis (BV), the overgrowth of diverse anaerobic bacteria in the vagina, is the most common cause of vaginal symptoms worldwide. BV frequently recurs after antibiotic therapy, and the best probiotic treatments only result in transient changes from BV-associated states to "optimal" communities dominated by a single species of Lactobacillus. Therefore, additional treatment strategies are needed to durably alter vaginal microbiota composition for patients with BV. Vaginal microbiota transplantation (VMT), the transfer of vaginal fluid from a healthy person with an optimal vaginal microbiota to a recipient with BV, has been proposed as one such alternative. However, VMT carries potential risks, necessitating strict safety precautions. Here, we present an FDA-approved donor screening protocol and detailed methodology for donation collection, storage, screening, and analysis of VMT material. We find that Lactobacillus viability is maintained for over six months in donated material stored at - 80 °C without glycerol or other cryoprotectants. We further show that species-specific quantitative PCR for L. crispatus and L. iners can be used as a rapid initial screening strategy to identify potential donors with optimal vaginal microbiomes. Together, this work lays the foundation for designing safe, reproducible trials of VMT as a treatment for BV.

Semen: A modulator of female genital tract inflammation and a vector for HIV-1 transmission

In order to establish productive infection in women, HIV must transverse the vaginal epithelium and gain access to local target cells. Genital inflammation contributes to the availability of HIV susceptible cells at the female genital mucosa and is associated with higher HIV transmission rates in women. Factors that contribute to genital inflammation may subsequently increase the risk of HIV infection in women. Semen is a highly immunomodulatory fluid containing several bioactive molecules with the potential to influence inflammation and immune activation at the female genital tract. In addition to its role as a vector for HIV transmission, semen induces profound mucosal changes to prime the female reproductive tract for conception. Still, most studies of mucosal immunity are conducted in the absence of semen or without considering its immune impact on the female genital tract. This review discusses the various mechanisms by which semen exposure may influence female genital inflammation and highlights the importance of routine screening for semen biomarkers in vaginal specimens to account for its impact on genital inflammation.

The use of PSA as a biomarker of recent semen exposure in female reproductive health studies

Semen contains potent soluble proteins, bacteria, viruses, activated immune cells as well as anti- and pro-inflammatory cytokines that may influence the inflammatory response and alter microbial composition of the female genital tract. The presence of semen in the female genital mucosa may be a significant confounder that most studies have failed to control for in their analysis. Prostate-specific antigen (PSA), a protein secreted by the prostate into the urethra during ejaculation, is a well-established biomarker of semen exposure. Several studies have demonstrated discordance between self-reports of sexual behavior and the presence of PSA. Recent semen exposure has been shown to promote pro-inflammatory responses, stimulate the recruitment of activated immune cells and decrease Lactobacilli abundance in the female genital mucosa. As a result, it is important to understand the concordance between self-reported consistent condom use and the presence of semen biomarkers. Furthermore, to ensure that the interpretation of data in clinical studies of the immunological and microbial environment in the female genital mucosa are accurate, it is essential to establish whether semen is present in the vaginal fluid. This review explores the impact of semen exposure on the mucosal microenvironment and assesses the use of the PSA as an objective biomarker of semen exposure to reduce reliance on self-reported sexual intercourse.

Transient association between semen exposure and biomarkers of genital inflammation in South African women at risk of HIV infection

INTRODUCTION

Semen induces mucosal changes in the female reproductive tract to improve pregnancy outcomes. Since semen-induced alterations are likely short-lived and genital inflammation is linked to HIV acquisition in women, we investigated the contribution of recent semen exposure on biomarkers of genital inflammation in women at high HIV risk and the persistence of these associations.

METHODS

We assessed stored genital specimens from 152 HIV-negative KwaZulu-Natal women who participated in the CAPRISA 008 trial between November 2012 and October 2014. During the two-year study period, 651 vaginal specimens were collected biannually (mean five samples per woman). Cervicovaginal lavage (CVL) was screened for prostate-specific antigen (PSA) by ELISA, whereas Y-chromosome DNA (YcDNA) detection and quantification were conducted by RT-PCR, representing semen exposure within 48 hours (PSA+YcDNA+) and semen exposure within three to fifteen days (PSA-YcDNA+). Soluble protein concentrations were measured in CVLs by multiplexed ELISA. T-cell frequencies were assessed in cytobrushes by flow-cytometry, and vulvovaginal swabs were used to detect common vaginal microbes by PCR. Linear mixed models adjusting for factors associated with genital inflammation and HIV risk were used to assess the impact of semen exposure on biomarkers of inflammation over multiple visits.

RESULTS

Here, 19% (125/651) of CVLs were PSA+YcDNA+, 14% (93/651) were PSA-YcDNA+ and 67% (433/651) were PSA-YcDNA-. Semen exposure was associated with how often women saw their partners, the frequency of vaginal sex in the past month, HSV-2 antibody detection, current gonorrhoea infection and Nugent Score. Both PSA detection (PSA+YcDNA+) and higher cervicovaginal YcDNA concentrations predicted increases in several cytokines, barrier-related proteins (MMP-2, TIMP-1 and TIMP-4) and activated CD4+CCR5+HLA-DR+ T cells (β = 0.050; CI 0.001 to 0.098; p = 0.046) and CD4+HLA-DR+ T cells (β = 0.177; CI 0.016 to 0.339; p = 0.032) respectively. PSA detection was specifically associated with raised pro-inflammatory cytokines (including IL-6, TNF-α, IP-10 and RANTES), and with the detection of BVAB2 (OR = 1.755; CI 1.116 to 2.760; p = 0.015), P. bivia (OR = 1.886; CI 1.102 to 3.228; p = 0.021) and Gardnerella vaginalis (OR = 1.815; CI 1.093 to 3.015; p = 0.021).

CONCLUSIONS

More recent semen exposure was associated with raised levels of inflammatory biomarkers and the detection of BV-associated microbes, which declined by three to fifteen days of post-exposure. Although transient, semen-induced alterations may have implications for HIV susceptibility in women.

The Impact of Semen Exposure on the Immune and Microbial Environments of the Female Genital Tract

Background: Semen induces an immune response at the female genital tract (FGT) to promote conception. It is also the primary vector for HIV transmission to women during condomless sex. Since genital inflammation and immune activation increase HIV susceptibility in women, semen-induced alterations at the FGT may have implications for HIV risk. Here we investigated the impact of semen exposure, as measured by self-reported condom use and Y-chromosome DNA (YcDNA) detection, on biomarkers of female genital inflammation associated with HIV acquisition. Methods: Stored genital specimens were collected biannually (mean 5 visits) from 153 HIV-negative women participating in the CAPRISA 008 tenofovir gel open-label extension trial. YcDNA was detected in cervicovaginal lavage (CVL) pellets by RT-PCR and served as a biomarker of semen exposure within 15 days of genital sampling. Protein concentrations were measured in CVL supernatants by multiplexed ELISA, and the frequency of activated CD4+CCR5+ HIV targets was assessed on cytobrush-derived specimens by flow cytometry. Common sexually transmitted infections (STIs) and bacterial vaginosis (BV)-associated bacteria were measured by PCR. Multivariable linear mixed models were used to assess the relationship between YcDNA detection and biomarkers of inflammation over time. Results: YcDNA was detected at least once in 69% (106/153) of women during the trial (median 2, range 1-5 visits), and was associated with marital status, cohabitation, the frequency of vaginal sex, and Nugent Score. YcDNA detection but not self-reported condom use was associated with elevated concentrations of several cytokines: IL-12p70, IL-10, IFN-γ, IL-13, IP-10, MIG, IL-7, PDGF-BB, SCF, VEGF, β-NGF, and biomarkers of epithelial barrier integrity: MMP-2 and TIMP-4; and with reduced concentrations of IL-18 and MIF. YcDNA detection was not associated with alterations in immune cell frequencies but was related to increased detection of P. bivia (OR = 1.970; CI 1.309-2.965; P = 0.001) at the FGT. Conclusion: YcDNA detection but not self-reported condom use was associated with alterations in cervicovaginal cytokines, BV-associated bacteria, and matrix metalloproteinases, and may have implications for HIV susceptibility in women. This study highlights the discrepancies related to self-reported condom use and the need for routine screening for biomarkers of semen exposure in studies of mucosal immunity to HIV and other STIs.

A novel nested polymerase chain reaction targeting the testis-specific protein Y-encoded family of genes for high sensitivity of recent semen exposure detection: Comparison with four other assays of semen detection

OBJECTIVES

Because self-report of sexual behaviours is prone to biases, biomarkers of recent semen exposure are increasingly used to assess unprotected sex. We aimed to present a novel nested polymerase chain reaction (PCR) assay targeting testis-specific protein Y-encoded (TSPY) genes and to compare its performance in detecting recent semen exposure with that of four other assays.

METHODS

Forty-five vaginal samples were selected at baseline of a prospective observational demonstration study of early antiretroviral treatment and pre-exposure prophylaxis among female sex workers in Benin. Semen exposure was assessed with: a rapid prostate-specific antigen (PSA) detection assay, a quantitative PCR targeting the sex-determining region (SRY) gene, a standard PCR targeting SRY, a standard PCR targeting TSPY, and a nested PCR targeting TSPY (n-TSPY). Because we had hypothesized that n-TSPY would be the most sensitive of the five assays while remaining specific, and as our results suggested that it was the case, sensitivity and specificity were calculated for each assay in comparison with n-TSPY.

RESULTS

The n-TSPY could detect male DNA at concentration 16 and 64 times lower compared to s-TSPY and s-SRY, respectively. Among the 45 vaginal samples, prevalences of semen exposure according to the different assays varied from 22.2% (95%CI: 11.2%-37.1%) to 70.5% (95%CI: 54.8%-83.2%), with the highest prevalence measured with n-TSPY. The n-TSPY products were of expected size and we observed no false-positive in female DNA controls. The assay that offered the second best performance in detecting semen exposure was the PSA rapid test, with a sensitivity of 61.3% and a specificity of 100% compared to n-TSPY.

CONCLUSIONS

Compared to n-TSPY, all other PCR assays had poor performance to detect semen exposure. The n-TSPY is an accessible assay that may have great utility in assessing semen exposure in studies where many factors are expected to accelerate biomarkers' clearance.

Daily Vaginal Swabs and Mobile Phone Sex Report for Assessing HIV Virion Exposure Prospectively Among a Cohort of Young Sexually Active Women in South Africa (HVTN 915)

BACKGROUND

Measurements of HIV exposure could help identify subpopulations at highest risk of acquisition and improve the design of HIV prevention efficacy trials and public health interventions. The HVTN 915 study evaluated the feasibility of self-administered vaginal swabs for detection of HIV virions to assess exposure.

METHODS

Fifty 18- to 25-year-old sexually active HIV-seronegative women using contraception were enrolled in Soweto, South Africa. Participants self-administered daily vaginal swabs and answered sexual behavior questions through mobile phone for 90 days. Clinician-administered vaginal swabs, behavioral questionnaires, HIV diagnostic testing, and counseling were performed at 8 clinic visits. Glycogen concentrations assessed adherence to swabbing. Y-chromosome DNA (Yc-DNA) assessed the accuracy of reported condom use. HIV exposure was measured by virion polymerase chain reaction in swabs from 41 women who reported unprotected vaginal sex during follow-up.

RESULTS

Glycogen was detected in 315/336 (93.8%) participant-collected and in all clinician-collected swabs. Approximately 20/39 daily swabs (51.3%) linked to mobile reports of unprotected sex tested positive for Yc-DNA, whereas 10/187 swabs collected after 3 days of abstinence or protected sex (5.3%) had detectable Yc-DNA. No participant became HIV infected during the study; yet, exposure to HIV was detected by nucleic acids in 2 vaginal swabs from 1 participant, collected less than 1 hour after coitus.

CONCLUSION

There was high adherence to daily vaginal swabbing. Daily mobile surveys had accurate reporting of unprotected sex. Detection of HIV in self-collected vaginal swabs from an uninfected participant demonstrated it was possible to measure HIV exposure, but the detection rate was lower than expected.

Genital mycoplasmas and ureaplasmas in cervicovaginal self-collected samples of reproductive-age women: prevalence and risk factors

The purpose of this study was to characterise the prevalence and risk factors associated with genital mycoplasmas ( Mycoplasma hominis [MH], M. genitalium [MG]) and ureaplasmas ( Ureaplasma urealyticum [UU], U. parvum [UP]) in Portuguese women of reproductive age. The cross-sectional study included 612 cervicovaginal self-collected samples from women aged 15–44 years, tested for MH, MG, UU, UP by polymerase chain reaction. Y chromosome (Yc) DNA was detected as a biomarker of recent unprotected sexual intercourse. The prevalences of UU, UP, MH and MG were 28.4% (95% confidence interval [CI] 25.0–32.1), 22.4% (95% CI 19.3–25.9), 8.5% (95% CI 6.5–11.0) and 0.8% (95% CI 0.4–1.9), respectively. Overall, women aged 20–29 years (odds ratio [OR] 1.78; P = 0.010) and the presence of Yc-DNA (OR 2.33; P = 0.038) were associated with an increased risk of UU. Lifetime number of sexual partners was a predictor of UU, UP and MH (OR 2.46; P < 0.001, OR 2.78; P < 0.001 and OR 1.55; P < 0.001, respectively, for more than one versus one partner). The prevalence of MG was low, while UU, UP and MH were common in Portuguese women of reproductive age. The presence of UU, UP and MH was associated with sexual activity (number of sexual partners), although the consequences of its prevalence are not fully understood and should be further investigated.

PrEP implementation research in Africa: what is new?

INTRODUCTION

Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings.

DISCUSSION

In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.

CONCLUSIONS

Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.

Assessment of the vaginal residence time of biomarkers of semen exposure

OBJECTIVE

The primary objective of this pilot study is to determine and compare the residence time in the vagina of biomarkers of semen exposure for up to 15 days post exposure. The biomarkers are prostate-specific antigen (PSA), Y chromosome DNA, the sex determining region of the Y chromosome (SRY) and testis-specific protein Y-encoded 4 (TSPY4). The secondary objectives are to determine if biomarker concentrations differed between intercourse and inoculation groups, to establish whether the sampling frequency post exposure affected biomarker concentrations and decay profile and to determine if biomarker concentrations in vaginal swabs obtained by the participant at home were similar to swabs obtained by the nurse in the clinic.

STUDY DESIGN

We randomized healthy women to unprotected intercourse (n=17) versus vaginal inoculation with the male partner's semen in the clinic (n=16). Women were then further randomized to have vaginal swabs obtained at either 7 or 4 time points after semen exposure, up to 15 days post exposure, either obtained at home by the participant or in the clinic by the research nurse.

RESULTS

PSA and SRY were markers of recent semen exposure. TSPY4 was detectable in approximately 50% of participants at 15 days post exposure. Unprotected intercourse resulted in significantly higher concentrations of select biomarkers. Sampling frequency and home versus clinic sampling had no significant effect on biomarker concentrations.

CONCLUSIONS

Objective biomarkers of recent or distant semen exposure may have great utility for verifying protocol compliance in a variety of clinical trials.

Herpes Simplex Virus Type-2 Cervicovaginal Shedding Among Women Living With HIV-1 and Receiving Antiretroviral Therapy in Burkina Faso: An 8-Year Longitudinal Study

Background. The impact of antiretroviral therapy (ART) on herpes simplex virus type-2 (HSV-2) replication is unclear. The aim of this study was to assess factors associated with cervicovaginal HSV-2 DNA shedding and genital ulcer disease (GUD) in a cohort of women living with human immunodeficiency virus type-1 (HIV-1) in Burkina Faso.

Methods. Participants were screened for cervicovaginal HSV-2 DNA, GUD, cervicovaginal and systemic HIV-1 RNA, and reproductive tract infections every 3–6 months over 8 years. Associations with HSV-2 shedding and quantity were examined using random-effects logistic and linear regression, respectively.

Results. Of the 236 women with data on HSV-2 shedding, 151 took ART during the study period. Cervicovaginal HSV-2 DNA was detected in 42% of women (99 of 236) in 8.2% of visits (151 of 1848). ART was associated with a reduction in the odds of HSV-2 shedding, which declined for each year of ART use (odds ratio [OR], 0.74; 95% confidence interval [CI], .59–.92). In the multivariable model, the impact of ART was primarily associated with suppression of systemic HIV-1 RNA (adjusted OR, 0.32; 95% CI, .15–.67). A reduction in the odds of GUD was also observed during ART, mainly in those with HIV-1 suppression (adjusted OR, 0.53; 95% CI, .25–1.11).

Conclusions. ART is strongly associated with a decrease in cervicovaginal HSV-2 shedding, and the impact was sustained over several years.

Y chromosome DNA in cervicovaginal self-collected samples of childbearing age women: Implications for epitheliotropic sexually transmitted infections?

AIMS

Assuming a possible association between Y chromosome (Yc)-DNA and sexually transmitted infection (STI) transmission rate, could Yc-DNA be related to an increased prevalence of Human Papillomavirus (HPV), Herpes Simplex Virus (HSV-1/2) and Chlamydia trachomatis (CT)? Could Yc-DNA be used to validate self-reported condom use and sexual behaviors?

MAIN METHODS

Cervicovaginal (CV) self-collected samples of 612 Portuguese women at childbearing age were tested for Yc, HPV, HSV-1/2 and CT by polymerase chain reaction (PCR).

KEY FINDINGS

The prevalence of Yc, HPV, CT and HSV-2 was 4.9%, 17.6%, 11.6% and 2.8%, respectively. There was a statistically significant trend for increased Yc-DNA prevalence in HPV positive samples [odds ratio (OR) 2.35, 95% confidence interval (CI) 1.03-5.31] and oral contraceptive (OC) use (OR 4.73, 95% CI 1.09-20.44). A protective effect of condom use was observed in Yc-DNA detection (OR 0.40, 95% CI 0.18-0.89). No statistically significant difference was found between Yc-DNA, CT and HSV-2 infection. HPV infection risk increased with age (>20 years), young age at first sexual intercourse (FSI) (≤18 years), >1 lifetime sexual partner (LSP) and OC use. Risk factors for CT infection were young age (≤20 years) and young age at FSI (≤18 years). HSV-2 infection risk increased with age (>20 years) and >1 LSP.

SIGNIFICANCE

Considering the prevalence of HPV and CT in Yc positive samples, we hypothesize a current infection due to recent sexual activity. The study of Yc PCR may add information as (i) a predictor of STI transmission and (ii) an indicative biomarker to validate self-reported condom use.

The use of biomarkers of semen exposure in sexual and reproductive health studies

Biomarkers of semen exposure have been used in studies investigating the safety and efficacy of barrier methods of contraception. They have been used as objective indicators of semen exposure when studying sexual behaviors and in human immunodeficiency virus/sexually transmitted infection research interventions where participants are advised to avoid unprotected sex. Semen biomarkers have also been used to assess or validate self-reported sexual behaviors or condom use in reproductive health settings. Prostate-specific antigen (PSA) and Y chromosome DNA (Yc-DNA) have each been evaluated in the past as semen biomarkers and are the most widely used in the field. While both are considered reliable for evaluating exposure to semen, each has unique characteristics. In this report, we summarize the literature and provide some considerations for reproductive health researchers who are interested in using PSA or Yc-DNA as semen biomarkers. We also synthesize our previous published work on the optimal conditions of collecting and storing specimens and assay performance in the presence of other vaginal products that may influence various assays. Semen biomarkers are innovative and promising tools to further study and better understand women's reproductive and sexual health and behavior. More research is needed to better understand the strengths, limitations, and optimal performance conditions of specific assays in vivo.

Cervicovaginal HIV-1 shedding in women taking antiretroviral therapy in Burkina Faso: a longitudinal study

BACKGROUND

Antiretroviral therapy (ART) reduces transmission of HIV-1. However, genital HIV-1 can be detected in patients on ART. We analyzed factors associated with genital HIV-1 shedding among high-risk women on ART in Burkina Faso.

METHODS

Plasma viral load (PVL) and enriched cervicovaginal lavage HIV-1 RNA were measured every 3-6 months for up to 8 years. Random-effects logistic and linear regression models were used to analyze associations of frequency and quantity of genital HIV-1 RNA with behavioral and biological factors, adjusting for within-woman correlation. The lower limit of detection of HIV-1 RNA in plasma and eCVL samples was 300 copies per milliliter.

RESULTS

One hundred and eighty-eight participants initiated ART from 2004 to 2011. PVL was detectable in 16% (171/1050) of visits, in 52% (90/174) of women. Cervicovaginal HIV-1 RNA was detectable in 16% (128/798) of visits with undetectable plasma HIV-1 RNA in 45% (77/170) of women. After adjusting for PVL, detectable cervicovaginal HIV-1 RNA was independently associated with abnormal vaginal discharge and use of nevirapine or zidovudine vs. efavirenz and stavudine, respectively; longer time on ART and hormonal contraception were not associated with increased shedding. The presence of bacterial vaginosis, herpes simplex virus-2 DNA, and the use of nevirapine vs efavirenz were independently associated with an increased quantity of cervicovaginal HIV-1 RNA.

CONCLUSIONS

Certain ART regimens, abnormal vaginal discharge, bacterial vaginosis, and genital herpes simplex virus-2 are associated with HIV-1 cervicovaginal shedding or quantity in women on ART after adjusting for PVL. This may reduce the effectiveness of ART as prevention in high-risk populations.

Telling truth from Ys: an evaluation of whether the accuracy of self-reported semen exposure assessed by a semen Y-chromosome biomarker predicts pregnancy in a longitudinal cohort study of pregnancy

OBJECTIVES

Adolescents may use condoms inconsistently or incorrectly, or may over-report condom use. This study used a semen exposure biomarker to evaluate the accuracy of female adolescents' reports of condom use and predict subsequent pregnancy.

METHODS

The sample comprised 715 sexually active African-American female adolescents, ages 15-21 years. At baseline, 6 months and 12 months, participants completed a 40-min interview and were tested for semen Y-chromosome with PCR from a self-administered vaginal swab. We predicted pregnancy from semen exposure under-report using multivariate regression controlling for oral contraception, reported condom use and coital frequency.

RESULTS

At the 3 surveys, 30%, 20% and 15% of adolescents who reported always using condoms tested positive for semen exposure. At 6 month follow-up, 20.4% and 16.2% of the adolescents who under-reported semen exposure reported pregnancy, a higher pregnancy rate than accurate reporters of semen exposure, even accurate reporters who reported never using condoms (14.2% and 11.8%). Under-reporters of semen exposure were 3.23 (95% CI (1.61, 6.45)) times as likely to become pregnant at 6-month follow-up and 2.21 (0.94, 5.20) times as likely to become pregnant at 12-month follow-up as accurate reporters who reported not using contraception, adjusting for self-reported coital frequency.

CONCLUSIONS

Adolescents who under-report semen exposure may be at uniquely high risk for unplanned pregnancy and STIs, and may also under-report coital frequency. Condom efficacy trials that rely on self-report may yield inaccurate results. Adapted to a clinical setting, the Y-chromosome PCR could alert women to incorrect or inconsistent condom use.

Do Jobs Work? Risk and Protective Behaviors Associated with Employment Among Disadvantaged Female Teens in Urban Atlanta

Adolescent employment predicts lower educational engagement and achievement and greater engagement with risk behaviors. Most research has studied middle class rather than disadvantaged adolescents. We identified risk and protective behaviors associated with employment using data from a 3-wave, 12-month study of 715 low-socio-economic status female African American adolescents who were ages 15-21 at baseline. Adolescents who were employed at wave 2 (n=214) were matched with adolescents who were not employed at wave 2 (n=422) using nearest-neighbor matching on baseline factors within propensity score calipers on factors including marijuana use, sex while high, pregnancy risk, and socioeconomic status. We compared employed and non-employed teens on risk behaviors including marijuana use, sex while high or drunk, and a biomarker for semen exposure in the past 14 days. Employed teens were 44% as likely to say that their boyfriend is their primary spending money source and 43% as likely to be emotionally abused, but these benefits did not persist after employment ended. Six months after employment, employed respondents reported using marijuana 57% more often and had sex while drunk or high 2.7 times as frequently. Women who were employed at both waves 2 and 3 were 17% as likely to have their boyfriend as a primary source of spending money and 13% more likely to graduate high school, but they used marijuana twice as often, alcohol 1.6 times as often, had 1.6 times as many sexual partners, and had sex while high or drunk 2.3 times as often. Female teens who work may avoid potentially coercive romantic relationships, but they may buy drugs or alcohol with their earnings.

Assessing the effect of hormonal contraception on HIV acquisition in observational data: challenges and recommended analytic approaches

INTRODUCTION

Determining whether hormonal contraception, particularly the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), increases a woman's risk of HIV acquisition is a priority question for public health. However, assessing the relationship between various hormonal contraceptive methods and HIV acquisition with observational data involves substantial analytic design issues and challenges. Studies to date have used inconsistent approaches and generated a body of evidence that is complex and challenging to interpret.

METHODS

In January 2013, the United States Agency for International Development and FHI 360 supported a meeting of epidemiologists, statisticians, and content experts to develop recommendations for future observational analyses of hormonal contraception and HIV acquisition.

RESULTS

Meeting participants generated recommendations regarding careful definition of exposure groups; handling potential confounders, mediators, and effect modifiers; estimating and addressing the magnitude of measurement error; using multiple methods to account for pregnancy; and exploring the potential for differential exposure to HIV-infected partners. Advantages and disadvantages of various statistical approaches to account for time-varying confounding and estimating total and direct effects were also discussed.

CONCLUSION

Implementing these recommendations in future observational hormonal contraception-HIV acquisition analyses will enhance interpretation of existing studies and strengthen the overall evidence base for this complex and important area.

Detection of two biological markers of intercourse: prostate-specific antigen and Y-chromosomal DNA

BACKGROUND

Although biological markers of women's exposure to semen from vaginal intercourse have been developed as surrogates for risk of infection or probability of pregnancy, data on their persistence time and clearance are limited.

STUDY DESIGN

During 2006-2008, 52 couples were enrolled for three 14-day cycles of abstinence from vaginal sex during which women were exposed in the clinic to a specific quantity (10, 100 or 1000 μL) of their partner's semen. Vaginal swabs were collected before and at 1, 6, 12, 24, 48, 72 and 144 h after exposure for testing for prostate-specific antigen (PSA) and Y-chromosome DNA (Yc DNA).

RESULTS

Immediately after exposure to 1000 μL of semen, the predicted sensitivity of being PSA positive was 0.96; this decreased to 0.65, 0.44, 0.21 and 0.07 at 6, 12, 24 and 48 h, respectively. Corresponding predicted sensitivity of being Yc DNA positive was 0.72 immediately postexposure; this increased to 0.76 at 1 h postexposure and then decreased to 0.60 (at 6 h), 0.63 (at 12 h), 0.49 (at 24 h), 0.21 (at 48 h), 0.17 (at 72 h) and 0.12 (at 144 h).

CONCLUSIONS

Overall findings suggest that PSA may be more consistent as a marker of very recent exposure and that Yc DNA is more likely to be detected in the vagina after 12 h postexposure compared to PSA.

TSPY4 is a novel sperm-specific biomarker of semen exposure in human cervicovaginal fluids; potential use in HIV prevention and contraception studies

BACKGROUND

Developing an objective, reliable method to determine semen exposure in cervicovaginal fluids is important for accurately studying the efficacy of vaginal microbicides and contraceptives. Y-chromosome biomarkers offer better stability, sensitivity, and specificity than protein biomarkers. TSPY4 belongs to the TSPY (testis-specific protein Y-encoded) family of homologous genes on the Y-chromosome. Using a multiplex PCR amplifying TSPY4, amelogenin, and Sex-determining region in the Y chromosome (SRY), our objective was to determine whether a gene in the TSPY family was a more sensitive marker of semen exposure in cervicovaginal fluids than SRY.

STUDY DESIGN

The multiplex polymerase chain reaction (PCR) was developed using sperm and vaginal epithelial (female) DNA. Diluted sperm DNA and mixed male/female DNA was used to determine the sensitivity of the multiplex PCR. Potential interference of TSPY4 amplification by components in cervicovaginal and seminal fluids was determined. TSPY4 and SRY amplification was also investigated in women participating in a separate IRB-approved clinical study in which cervicovaginal swab DNA was collected before semen exposure and at various time points after exposure.

RESULTS

TSPY4, SRY, and amelogenin were amplified in sperm DNA, but only amelogenin in female DNA. The limit of sperm DNA from which TSPY4 could be amplified was lower than SRY (4 pg vs 80 pg). TSPY4 could also be amplified from mixed male/female DNA. Amplification was not affected by cervicovaginal and seminal components. Using cervicovaginal swab DNA from three women before and after semen exposure, TSPY4 was detected up to 72 h post exposure while SRY detection was observed up to 24-48 h. TSPY4 was detected up to 7 days post exposure in one out of three women.

CONCLUSIONS

We have demonstrated that TSPY4 is a new sensitive, and sperm-specific biomarker. The multiplex PCR incorporating this new biomarker has potential to be an objective measure for determining semen exposure in clinical trials of vaginal products such as contraceptives and HIV pre/post-exposure prophylaxis agents.

Biological validation of self-reported condom use among sex workers in Guinea

Self-reported condom use may be prone to social desirability bias. Our aim was to assess the validity of self-reported condom use in a population of female sex workers using prostate specific antigen (PSA) as a gold standard biomarker of recent unprotected vaginal intercourse. We collected data on 223 sex-workers in Conakry, Guinea in order to assess the sensitivity and specificity of self-reported condom use as well as to examine the predictors of discordance between self-report and PSA presence. PSA was detected in 38.4% of samples. Sensitivity of self-reported condom use was 14.6% and its specificity was 94.7%. Self-perceived high risk of HIV infection was the only significant independent predictor of misreported condom use. PSA could be useful to validate self-reported condom use in surveys and to allow a better understanding of factors associated with social desirability in sexual behaviour reporting.

Infection of macrophages and dendritic cells with primary R5-tropic human immunodeficiency virus type 1 inhibited by natural polyreactive anti-CCR5 antibodies purified from cervicovaginal secretions

Heterosexual contact is the primary mode of human immunodeficiency virus (HIV) type 1 (HIV-1) transmission worldwide. The chemokine receptor CCR5 is the major coreceptor that is associated with the mucosal transmission of R5-tropic HIV-1 during sexual intercourse. The CCR5 molecule is thus a target for antibody-based therapeutic strategies aimed at blocking HIV-1 entry into cells. We have previously demonstrated that polyreactive natural antibodies (NAbs) from therapeutic preparations of immunoglobulin G and from human breast milk contain NAbs directed against CCR5. Such antibodies inhibit the infection of human macrophages and T lymphocytes by R5-tropic isolates of HIV in vitro. In the present study, we demonstrate that human immunoglobulins from the cervicovaginal secretions of HIV-seronegative or HIV-seropositive women contain NAbs directed against the HIV-1 coreceptor CCR5. Natural affinity-purified anti-CCR5 antibodies bound to CCR5 expressed on macrophages and dendritic cells and further inhibited the infection of macrophages and dendritic cells with primary and laboratory-adapted R5-tropic HIV but not with X4-tropic HIV. Natural anti-CCR5 antibodies moderately inhibited R5-tropic HIV transfer from monocyte-derived dendritic cells to autologous T cells. Our results suggest that mucosal anti-CCR5 antibodies from healthy immunocompetent donors may hamper the penetration of HIV and may be suitable for use in the development of novel passive immunotherapy regimens in specific clinical settings of HIV infection.

Cervicovaginal HIV-1 and herpes simplex virus type 2 shedding during genital ulcer disease episodes

OBJECTIVE

To investigate correlates of herpes simplex virus type 2 (HSV-2) DNA and HIV-1 RNA among women with genital ulcer disease (GUD).

DESIGN

Baseline data from a randomized placebo-controlled trial of episodic herpes treatment in Ghana and the Central African Republic.

METHODS

GUD aetiology was determined by polymerase chain reaction (PCR) from a lesional swab. Real-time PCR was used to quantify HIV-1 RNA, and HSV-2 DNA in cervicovaginal lavages (CVL) and HIV-1 RNA in plasma. Genital infection was defined as the presence of virus in the lesion or CVL.

RESULTS

Of 441 women enrolled, 79.0% were HSV-2 seropositive, 46.6% were HIV-1 seropositive, and 50.0% had an HSV-2 ulcer. Among 180 HSV-2/HIV-1 co-infected women, cervicovaginal HIV-1 RNA was detected more frequently in women with HSV-2 ulcers (67.9%) or cervicovaginal HSV-2 DNA only (72.3%) compared with women without genital HSV-2 infection (42.4%) (P = 0.004). Women with genital HSV-2 infection had higher median cervicovaginal HIV-1-RNA loads (3.14 log10 copies/mL versus 2.10 log10 copies/mL; P = 0.003), higher plasma HIV-1-RNA loads (median 5.10 versus 4.65 log10 copies/mL; P = 0.07), and lower median CD4 cell counts) (198 versus 409 cells/mm, P = 0.03). Cervicovaginal HIV-1 RNA and HSV-2 DNA were significantly correlated after adjusting for plasma HIV-1 RNA and CD4 cell counts (P < 0.001) and a 10-fold increase in cervicovaginal HSV-2 DNA was associated with a 1.7-fold increase in plasma HIV-1 RNA (P = 0.003).

CONCLUSION

Genital HSV-2 infection is associated with increased cervicovaginal and plasma HIV-1 RNA among co-infected women with genital ulcers, independently of the level of immunodeficiency, highlighting the close interaction between these two viruses and the role of HSV-2 as a co-factor for the sexual transmission of HIV-1.

Biomarkers of semen in the vagina: applications in clinical trials of contraception and prevention of sexually transmitted pathogens including HIV

Biomarkers of vaginal exposure to semen, long used in forensic medicine, are now becoming important in the development of vaginal microbicides to prevent HIV/STIs and the development of contraceptives. Semen biomarkers could help evaluate the safety of a new physical or chemical barrier, give preliminary indication of the effectiveness of physical barriers such as diaphragms or condoms, and provide information on unprotected intercourse among participants in a clinical trial who have been advised to use condoms. Candidate biomarkers of semen exposure fall into two broad categories: (1) biomarkers of seminal plasma, among which prostate-specific antigen (PSA) is the best characterized; and (2) biomarkers of spermatozoa and other cells present in semen. This paper, authored by a working group of investigators performing research in the field of semen biomarkers, summarizes the characteristics of an ideal semen biomarker, reviews preclinical and clinical data on existing and potential biomarkers, and outlines the steps that should be carried out to develop an improved biomarker of semen exposure.

Influence of storage temperature on the stability of HIV-1 RNA and HSV-2 DNA in cervicovaginal secretions collected by vaginal washing

Variability in the handling of samples of genital secretions prior to quantitation of HIV-1 RNA and HSV DNA may profoundly affect both the detection and quantitation of these nucleic acids. Over 144 h, we evaluated, the influence of storage temperature (4 degrees C, 20 degrees C, 30 degrees C) on the quantity of HIV-1 RNA and HSV-2 DNA in HIV and HSV negative cervicovaginal lavage pools spiked with known amounts of HIV-1 and HSV-2 and in HIV-1 and HSV-2 co-infected cervicovaginal lavage pools. The level of viral nucleic acids remained stable at 4 degrees C for 24h but decreased significantly when cervicovaginal lavages were stored at 20 degrees C and 30 degrees C, demonstrating that, cervicovaginal lavages to be quantified for viral RNA or DNA require, at minimum, immediate storage at 4 degrees C.

Real-time PCR quantification of genital shedding of herpes simplex virus (HSV) and human immunodeficiency virus (HIV) in women coinfected with HSV and HIV

The accuracy and usefulness of laboratory-developed real-time PCR procedures using a Light Cycler instrument (Roche Diagnostics) for detecting and quantifying human immunodeficiency virus type 1 (HIV-1) RNA and DNA as well as herpes simplex virus type 1 (HSV-1)/HSV-2 DNA in cervicovaginal secretions from women coinfected with HIV and HSV were evaluated. For HIV-1, the use of the NEC152 and NEC131 primer set and the NEC-LTR probe in the long terminal repeat gene allowed us to detect accurately the majority of HIV-1 subtypes of group M circulating in sub-Saharan Africa, including subtypes A, B, C, D, and G as well as circulating recombinant forms 02 and 11. The detection threshold of real-time PCR for HIV in cervicovaginal lavage samples was 5 copies per assay for both RNA and DNA; the intra- and interassay coefficients of variation of C(T) values were 1.30% and 0.69% (HIV-1 RNA) and 1.84% and 0.67% (HIV-1 DNA), respectively. Real-time PCR for HSV using primers and probe targeting the HSV DNA polymerase gene allowed both detection and quantification of HSV DNA and also differentiation between HSV-1 and HSV-2 genotypes. The detection threshold of real-time PCR for HSV was 5 copies per assay; the intra- and interassay coefficients of variation of C(T) values were 0.96% and 1.49%, respectively. Both manual and automated silica-based procedures were appropriate for combined extraction of HIV and HSV genomes from female genital secretions. Taken together, these findings indicate that real-time PCR may be used as a unique nucleic acid amplification procedure to detect and quantify HIV and HSV genomes in cervicovaginal secretions and thus to assess at reduced costs the genital shedding of both viruses in women included in intervention studies.

Association of genital shedding of herpes simplex virus type 2 and HIV-1 among sex workers in rural Zimbabwe

INTRODUCTION

Herpes simplex virus type 2 (HSV-2) facilitates sexual acquisition of HIV-1 but data on transmission are less clear. In this study the interaction between genital shedding of HIV-1 and HSV-2 was explored among Zimbabwean sex workers.

METHODS

Women (n = 214) were interviewed about genital symptoms. Blood samples were analysed for HIV-1 and HSV-2 antibodies, HIV-1 plasma viral load (PVL) and CD4 lymphocyte count and genital swabs for detection of HIV-1 and HSV-2 genital shedding, Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis, and a cervico-vaginal lavage (CVL) for quantitative measurement of HIV-1 shedding. Shedding analyses were undertaken on women co-infected with HSV-2 and HIV-1.

RESULTS

A total of 124 women were co-infected with HIV-1 and HSV-2; 58 were infected with HSV-2 alone. Most HIV-1-infected women were co-infected with HSV-2 (95.4%). Genital HIV-1 shedding was detected in 84.3% of co-infected women and was associated with low CD4 cell count and high PVL but not with reported symptoms of genital herpes or genital shedding of HSV-2. There was no difference in HIV-1 shedding among women shedding HSV-2 (79.3%) and women not shedding HSV-2 (83.2%) (P = 0.64). The adjusted odds ratio for HIV-1 shedding between HSV-2 shedders and non-shedders was 0.8 [95% confidence interval (CI), 0.2-3.3]. HIV-1 PVL(log10) and CVL viral load(log10) were correlated (r = 0.38; 95%CI, 0.2-0.5). After adjusting for PVL, genital symptoms and age, HSV-2 shedding had no effect on CVL viral load (P = 0.13).

CONCLUSION

Rate and quantity of HIV-1 genital shedding do not appear to be altered by presence of HSV-2 genital shedding.

Modified isocratic capillary electrophoresis detection of cell-free DNA in semen

PURPOSE

The objectives were: i) to analyze semen for the presence of cell-free DNA and ii) to determine the association between sperm parameters and cell-free DNA.

METHODS

Cell-free DNA in semen (N = 25 cases) were detected using the modified capillary gel electrophoresis (CE) procedure. SYBR-Gold was used to stain high (12 Kb) and low (1 Kb) molecular weight DNA fragments and the images analyzed.

RESULTS

The quantity of low-molecular weight cell-free DNA was positively correlated to rapid progression, curvilinear velocity (>40 microm/s), normal strict morphology and capacitation index. High-molecular weight cell-free DNA intensity index was negatively correlated to post-wash hyperactivation. Sperm concentration was not related to cell-free DNA quantity. The sperm freezing process did not increase cell-free DNA but reduced the more labile low-molecular weight cell-free DNA.

CONCLUSIONS

Cell-free DNA present in semen was correlated to important sperm parameters linked to normal sperm function. The data suggested the possible use of cell-free DNA as a marker of semen quality. This study reports on the novel finding of cell-free DNA released along with sperm during each ejaculation.

Polymerase chain reaction detection of Y chromosome sequences in vaginal fluid: preliminary studies of a potential biomarker for sexual behavior

BACKGROUND

Self-reported measures of sexual behavior are subject to nontrivial reporting biases.

OBJECTIVE

The objective of this study was to develop a behavioral biomarker of recent sexual activity among females that is inexpensive, easily administered, and can be used in low sexually transmitted disease prevalence populations.

METHODS

We developed a polymerase chain reaction (PCR) assay to detect Y chromosome (Yc) fragments. The Yc primers were developed against a 200-basepair (bp) microsatellite repeat sequence, which is unique to the male genome. A standard PCR technique was used. Assay sensitivity was determined quantitatively using donated semen samples. To assess longevity of detectability, we recruited female subjects in monogamous relationships. Seventeen subjects had unprotected intercourse followed by 3 weeks of abstinence from vaginal intercourse. Self-administered vaginal swabs (SAVS) were collected every other day. In addition to the swabs, subjects kept daily sexual diaries. Swabs were processed by semiquantitative PCR, and Yc decay curves were determined for each subject. The half-life of Yc in vaginal fluid was calculated on the collection of individual decay curves by a random-effects regression model approach.

RESULTS

The sensitivity of our Yc-PCR assay was determined to be 5 copies of Yc. In the longevity studies, Yc was detectable in SAVS up to 15 postcoital days (PCD). Mean Yc DNA concentration in SAVS eluate followed an exponential decay pattern for each subject. Mean concentrations were 66.7 ng/mL at PCD-1, 20.6 ng/mL at PCD-7, and 4.5 ng/mL at PCD-15. The estimated half-life for Yc clearance was 3.83 days.

CONCLUSION

The swab-based Yc-DNA PCR assay can detect coitus in women for a 2-week retrospective period. This can be used to validate sexual behavior-reporting and condom use in women and promises to be a useful tool in sexual behavior research.

High prevalence of high-risk oncogenic human papillomaviruses harboring atypical distribution in women of childbearing age living in Libreville, Gabon

The extent of human papillomavirus (HPV) genital shedding and type-specific diversity were evaluated in 354 consecutive women of childbearing age living in Libreville, Gabon. Detection of HPV DNA was performed by PCR using the MY09/MY11 primer set on DNA extracted from endocervical swabs. All PCR positive specimens were subjected to direct sequencing and HPV genotypes were identified on the basis of >95% sequence homology in the L1 region. Reverse line blot hybridization assay was used when a genotype could not be resolved by sequencing alone. HPV DNA was detected in 163 (46%) women, all clinically asymptomatic for HPV-related lesions. The highest prevalence of genital HPV detection (45%) was in the age group from 22 to 29 years. A total of 90 women (55%) harbored high-risk (HR) genotypes, with the most common being HPV-53 (19; 12%), HPV-58 (17; 11%), and HPV-16 (16; 10%). Low-risk genotypes were found in 36 (22%) women with HPV-54 and HPV-70 being the most frequently detected (17; 11% and 10; 6%, respectively). Finally 37 women (23%) tested positive for genotypes of unknown oncogenic risk, the most common in this category being HPV-83 (20; 12%). Multiple infections were detected in 35 (21%) women. By multivariate analysis, HPV genital shedding was significantly associated with young age (OR: 0.34; P < 0.007). The multivalent vaccine currently available against cervical carcinomas, is only active against HPV-16 and HPV-18, and will thus have a low impact in this setting.

Mucosal humoral immune response to hepatitis C virus E1/E2 surface glycoproteins and HCV shedding in saliva and cervicovaginal fluids from chronically HCV-infected patients

BACKGROUND/AIMS

We herein focused on identifying biological factors possibly involved in non-parenteral transmission of hepatitis C virus (HCV), such as HCV excretion patterns and antibody-based immunity to the virus in saliva and/or cervicovaginal secretions (CVS).

METHODS

Paired blood, saliva and cervicovaginal lavage samples were obtained from HCV-RNA plasma-positive hemoglobin (Hb) antigen and HIV-seronegative, HCV-seropositive males (n=13) and females (n=21). HCV-specific antibodies were detected by ELISA in paired samples, and HCV-RNA was detected in cell-free and cell-associated body fluids.

RESULTS

Antibodies to E1 HCV surface glycoprotein of the IgG and IgA isotypes showed similar, but less pronounced, profiles as IgG and IgA to E2. HCV-specific IgG and IgA in mucosal fluids likely originated predominantly from the systemic compartment, because HCV-specific mucosal immunoglobulins involved primarily monomeric antibodies, including monomeric IgA, and because their specific activities for HCV antigens in corporeal fluids were similar to those in paired serum (Se). Viral shedding in saliva or CVS was restricted to cell-associated, non-replicating strand((+)) HCV-RNA in 42% (12 out of 28) of saliva and in 19% (four out of 21) of cervicovaginal fluids.

CONCLUSIONS

The association in body fluids of HCV-specific IgG, and to a lesser extent IgA, directed to E1/E2 surface glycoproteins (which may block critical steps of virus-cell interactions), of undetectable free viral RNA, and of occasional non-replicating cell-associated HCV, suggests a resulting poor infectivity of saliva or cervicovaginal fluid in chronically HCV-infected individuals. Taken together, these observations provide the basis for the low risk of non-parenteral transmission of HCV infection.