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1.  Prevalence of Bacterial Vaginosis and Impact of Genital Hygiene Practices in Non-Pregnant Women in Zanjan, Iran 
Oman Medical Journal  2009;24(4):288-293.
Abstract
Objectives
Bacterial vaginosis is one of the most common causes of reproductive tract infection (RTI), it’s prevalence is influenced by many factors. The aim of this study is to determine the prevalence of bacterial vaginosis and impact of sexual and genital hygienie practices and socio-demographic characteristics in non pregnant women of Zanjan province in Iran.
Methods
500 non-pregnant, married women were randomly selected for this study. This is a descriptive-analytic study conducted among non-pregnant referred to primry healthcare centres in Zanjan between May to August 2006. Following gynecological examination and vaginal sample collection by physicians, bacterial vaginosis was confirmed by Nugent criteria, tricomoniasis by direct microscopy and candidiasis by direct microscopic observation and evaluation of presenting clinical signs of vulvovaginitis.
Results
The prevalence of RTI was 27.6%. Out of which 16.2% was devoted to bacterial vaginosis (BV), 6.6% to trichomoniasis and 4.8% to Vulvovaginal candidiasis (VVC). In contrast to coital hygiene, there was a significant correlation between menstrual and individual vaginal hygiene and BV (p<0.01 and p<0.001) respectively. There was a significant correlation between BV and education (p<0.025), number of pregnancy (p<0.05) and method of contraception (p<0.005). No significant correlation was observed between age, age of marriage and abortion.
Conclusion
The data obtained suggests that the prevalence rate of BV is relatively high and could be affected by hygiene behaviors and certain socio-demographic characteristics, which indicate the need for comprehensive, scheduled programs of healthcare educations, aimed at reducing BV prevalence.
doi:10.5001/omj.2009.58
PMCID: PMC3243866  PMID: 22216382
2.  Bacterial Vaginosis Associated with Increased Risk of Female-to-Male HIV-1 Transmission: A Prospective Cohort Analysis among African Couples 
PLoS Medicine  2012;9(6):e1001251.
In a prospective study, Craig Cohen and colleagues investigate the association between bacterial vaginosis and the risk of female-to-male HIV-1 transmission.
Background
Bacterial vaginosis (BV), a disruption of the normal vaginal flora, has been associated with a 60% increased risk of HIV-1 acquisition in women and higher concentration of HIV-1 RNA in the genital tract of HIV-1–infected women. However, whether BV, which is present in up to half of African HIV-1–infected women, is associated with an increase in HIV-1 transmission to male partners has not been assessed in previous studies.
Methods and Findings
We assessed the association between BV on female-to-male HIV-1 transmission risk in a prospective study of 2,236 HIV-1–seropositive women and their HIV-1 uninfected male partners from seven African countries from a randomized placebo-controlled trial that enrolled heterosexual African adults who were seropositive for both HIV-1 and herpes simplex virus (HSV)-2, and their HIV-1–seronegative partners. Participants were followed for up to 24 months; every three months, vaginal swabs were obtained from female partners for Gram stain and male partners were tested for HIV-1. BV and normal vaginal flora were defined as a Nugent score of 7–10 and 0–3, respectively. To reduce misclassification, HIV-1 sequence analysis of viruses from seroconverters and their partners was performed to determine linkage of HIV-1 transmissions. Overall, 50 incident HIV-1 infections occurred in men in which the HIV-1–infected female partner had an evaluable vaginal Gram stain. HIV-1 incidence in men whose HIV-1–infected female partners had BV was 2.91 versus 0.76 per 100 person-years in men whose female partners had normal vaginal flora (hazard ratio 3.62, 95% CI 1.74–7.52). After controlling for sociodemographic factors, sexual behavior, male circumcision, sexually transmitted infections, pregnancy, and plasma HIV-1 RNA levels in female partners, BV was associated with a greater than 3-fold increased risk of female-to-male HIV-1 transmission (adjusted hazard ratio 3.17, 95% CI 1.37–7.33).
Conclusions
This study identified an association between BV and increased risk of HIV-1 transmission to male partners. Several limitations may affect the generalizability of our results including: all participants underwent couples HIV counseling and testing and enrolled in an HIV-1 prevention trial, and index participants had a baseline CD4 count ≥250 cells/mm3 and were HSV-2 seropositive. Given the high prevalence of BV and the association of BV with increased risk of both female HIV-1 acquisition and transmission found in our study, if this association proves to be causal, BV could be responsible for a substantial proportion of new HIV-1 infections in Africa. Normalization of vaginal flora in HIV-1–infected women could mitigate female-to-male HIV-1 transmission.
Trial Registration: ClinicalTrials.com NCT00194519
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Since the first reported case of AIDS in 1981, the number of people infected with HIV, the virus that causes AIDS, has risen steadily. By the end of 2010, 34 million people were living with HIV/AIDS. At the beginning of the epidemic more men than women were infected with HIV. Now, however, 50% of all adults infected with HIV are women and in sub-Saharan Africa, where two-thirds of HIV-positive people live, women account for 59% of people living with HIV. Moreover, among 15–24 year-olds, women are eight times more likely than men to be HIV-positive. This pattern of infection has developed because most people in sub-Saharan Africa contract HIV through unprotected heterosexual sex. The risk of HIV transmission for both men and women in Africa and elsewhere can be reduced by abstaining from sex, by only having one or a few partners, by always using condoms, and by male circumcision. In addition, several studies suggest that antiretroviral therapy (ART) greatly reduces HIV transmission.
Why Was This Study Done?
Unfortunately, in sub-Saharan Africa, only about a fifth of HIV-positive people are currently receiving ART, which means that there is an urgent need to find other effective ways to reduce HIV transmission in this region. In this prospective cohort study (a type of study that follows a group of people for some time to see which personal characteristics are associated with disease development), the researchers investigate whether bacterial vaginosis—a condition in which harmful bacteria disrupt the normal vaginal flora—increases the risk of female-to-male HIV transmission among African couples. Bacterial vaginosis, which is extremely common in sub-Saharan Africa, has been associated with an increased risk of HIV acquisition in women and induces viral replication and shedding in the vagina in HIV-positive women, which may mean that HIV-positive women with bacterial vaginosis are more likely to transmit HIV to their male partners than women without this condition. If this is the case, then interventions that reduce the incidence of bacterial vaginosis might be valuable HIV prevention strategies.
What Did the Researchers Do and Find?
The researchers analyzed data collected from 2,236 heterosexual African couples enrolled in a clinical trial (the Partners in Prevention HSV/HIV Transmission Study) whose primary aim was to investigate whether suppression of herpes simplex virus infection could prevent HIV transmission. In all the couples, the woman was HIV-positive and the man was initially HIV-negative. The female partners were examined every three months for the presence of bacterial vaginosis and the male partners were tested regularly for HIV infection. The researchers also determined whether the men who became HIV-positive were infected with the same HIV strain as their partner to check that their infection had been acquired from this partner. The HIV incidence in men whose partners had bacterial vaginosis was 2.9 per 100 person-years (that is, 2.9 out of every 100 men became HIV-positive per year) whereas the HIV incidence in men whose partners had a normal vaginal flora was 0.76 per 100 person-years. After controlling for factors that might affect the risk of HIV transmission such as male circumcision and viral levels in female partner's blood, the researchers estimated that bacterial vaginosis was associated with a 3.17-fold increased risk of female-to-male HIV transmission in their study population.
What Do These Findings Mean?
These findings suggest that HIV-positive African women with bacterial vaginosis are more than three times as likely to transmit HIV to their male partners as those with a normal vaginal flora. It is possible that some unknown characteristic of the men in this study might have increased both their own risk of HIV infection and their partner's risk of bacterial vaginosis. Nevertheless, because bacterial vaginosis is so common in Africa (half of the women in this study had bacterial vaginosis at least once during follow-up) and because this condition is associated with both female HIV acquisition and transmission, these findings suggest that bacterial vaginosis could be responsible for a substantial proportion of new HIV infections in Africa. Normalization of vaginal flora in HIV-infected women by frequent presumptive treatment with antimicrobials (treatment with a curative dose of antibiotics without testing for bacterial vaginosis) or possibly by treatment with probiotics (live “good” bacteria) might, therefore, reduce female-to-male HIV transmission in sub-Saharan Africa.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001251.
Information is available from the US National Institute of Allergy and infectious diseases on all aspects of HIV infection and AIDS and on bacterial vaginosis
The US Centers for Disease Control and Prevention has information on all aspects of HIV/AIDS, including specific information about HIV/AIDS and women; it also has information on bacterial vaginosis (in English and Spanish)
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment, and information on bacterial vaginosis and HIV transmission (in several languages)
Information is available from Avert, an international AIDS nonprofit group on many aspects of HIV/AIDS, including detailed information on HIV and AIDS prevention, on women, HIV and AIDS and on HIV/AIDS in Africa (in English and Spanish); personal stories of women living with HIV are available; the website Healthtalkonline also provides personal stories about living with HIV
More information about the Partners in Prevention HSV/HIV Transmission Study is available
doi:10.1371/journal.pmed.1001251
PMCID: PMC3383741  PMID: 22745608
3.  Evaluation of two clinical protocols for the management of women with vaginal discharge in southern Thailand 
Sexually Transmitted Infections  1998;74(3):194-201.
OBJECTIVES: (1) To compare the effectiveness of two clinical protocols for the management of vaginal discharge in the situations where no laboratory facilities are available but speculum examination is possible and where basic laboratory facilities are available. (2) To determine clinical and simple laboratory indicators for diagnosis of patients with vaginal discharge in the local setting. DESIGN: Alternate allocation of subjects to one of two management protocols. SUBJECTS: Women presenting to university gynaecology outpatients department with a complaint of vaginal discharge. METHODS: Subjects were alternately allocated management according to one of two protocols: one without (group A) and one with (group B) immediate access to results of basic laboratory tests. Full clinical assessment including speculum examination and microbiological assessment for infection with gonorrhoea, chlamydia, candida, trichomonas, and bacterial vaginosis was performed on all women. Follow up assessment of clinical and microbiological response was performed 1-2 weeks later. RESULTS: At initial assessment, both groups were similar in all respects except that more group B women had inflammation of the vulva. The prevalences of various conditions were: candidiasis 22%, bacterial vaginosis 38%, trichomoniasis 4%, chlamydia 4%, gonorrhoea 0.4%. There was no association between any demographic characteristic and diagnosis of cause of the discharge. Both protocols resulted in clinically and statistically significant improvements for women with candidiasis, bacterial vaginosis, and trichomoniasis. There were no clinically important differences in outcomes between the two protocols. The sensitivities and specificities of various indicators were: curd-like vaginal discharge for candidiasis, 72% and 100%; homogeneous vaginal discharge for bacterial vaginosis or trichomoniasis, 94% and 88%; absent or scanty lactobacilli for bacterial vaginosis, 99% and 68%; > 20% clue cells for bacterial vaginosis, 81% and 99%; visible endocervical mucopus for chlamydia or gonorrhoea, 36% and 86%; microscopic endocervical mucopus for chlamydia or gonorrhoea, 64% and 69%. CONCLUSIONS: Both protocols were equally effective in managing women with abnormal vaginal discharge. Simple clinical indicators for candidiasis, bacterial vaginosis, or trichomonas as in protocol A are sufficiently sensitive and specific for use in situations with no laboratory support. A modification to protocol A could increase detection of bacterial vaginosis at basic health service level. Further work is needed to identify appropriate indicators for infection with chlamydia or gonorrhoea. 



PMCID: PMC1758115  PMID: 9849555
4.  Prevalence of bacterial vaginosis among pregnant women attending antenatal care in Tikur Anbessa University Hospital, Addis Ababa, Ethiopia 
BMC Research Notes  2014;7(1):822.
Background
Bacterial vaginosis is one of the most common genital tract infections among reproductive age group. The prevalence of bacterial vaginosis varies from country to country even in the same country it varies among populations of interest. Different social and sexual factors can contribute to the development of bacterial vaginosis. The aim of this study was to determine the prevalence of bacterial vaginosis and to identify the possible risk factors associated among pregnant women attending antenatal care in Tikur Anbessa University Hospital, Addis Ababa, Ethiopia.
Methods
Randomly selected 57 symptomatic and 195 asymptomatic pregnant women aged between 18 and 40 years visiting obstetric and gynecological clinic from November 2011 to April 2012 screenedusing Gram stain Nugent scoring system. Statistical analysis like univariate analysis to calculate frequencies and proportions, bivariate analysis to see association of selected exposure variables with the outcome variable, and multivariate analysis to check the association of possible factors with bacterial vaginosis by adjusting potential confounding factors was calculated using SPSS (Version 16.0).
Results
The prevalence of bacterial vaginosis is 19.4% using Gram stain Nugent scoring system. In addition, prevalence of bacterial vaginosis is 31.6% and 15.9% among symptomatic and asymptomatic pregnant women respectively. A high percentage of bacterial vaginosis positive pregnant women were asymptomatic (63.3%). 36.7% bacterial vaginosis positive pregnant women reported abnormal vaginal discharge with or without unpleasant smell. Multiple lifetime sexual partner (OR: 8.6; 95% CI: 2.5, 29) and previous history of spontaneous abortion (OR: 5.9; 95% CI: 1.5, 23) had remained significantly associated with prevalence of bacterial vaginosis.
Conclusion
The prevalence of bacterial vaginosis is higher among asymptomatic pregnant women and associated with the factors previous history of multiple lifetime sexual partner and spontaneous abortion.
doi:10.1186/1756-0500-7-822
PMCID: PMC4247656  PMID: 25409756
Bacterial vaginosis; Pregnancy; Prevalence
5.  Comparison of Nucleic Acid Amplification Assays with BD Affirm VPIII for Diagnosis of Vaginitis in Symptomatic Women 
Journal of Clinical Microbiology  2013;51(11):3694-3699.
A commercially available, nonamplified, nucleic acid probe-based test system (BD Affirm VPIII) was compared with nucleic acid amplification (NAA)-based assays for determining the etiology of vaginitis in a cohort of 323 symptomatic women. First, a semiquantitative, multiplexed PCR assay (BV-PCR) and the Affirm VPIII Gardnerellavaginalis test were compared with a unified bacterial-vaginosis (BV) reference standard incorporating both Nugent Gram stain scores and Amsel clinical criteria. In the evaluable population of 305 patients, BV-PCR was 96.9% (191/197) sensitive and 92.6% specific (100/108) for BV, while Affirm VPIII was 90.1% sensitive (179/197) and 67.6% specific (73/108). Second, a multiplexed PCR assay detecting Candida albicans and Candida glabrata (CAN-PCR) was compared with the Affirm VPIII Candida test using a reference standard for vulvovaginal candidiasis (VVC) of yeast culture plus exclusion of alternate vaginitis etiologies. In the population evaluated (n = 102), CAN-PCR was 97.7% sensitive (42/43) and 93.2% specific (55/59) and Affirm VP III was 58.1% sensitive (25/43) and 100% specific (59/59) for VVC. Finally, the results of a commercial NAA test (GenProbe Aptima Trichomonas vaginalis assay; ATV) for T. vaginalis were compared with the Affirm VPIII Trichomonas vaginalis test. In the absence of an independent reference standard for trichomonal vaginitis (TV), a positive result in either assay was deemed to represent true infection. In the evaluable cohort of 388 patients, the sensitivity of ATV was 98.1% (53/54) versus 46.3% (25/54) for Affirm VPIII. The diagnostic accuracy of the combined NAA-based test construct was approximately 20 to 25% higher than that of the Affirm VPIII when modeled in populations with various prevalences of infectious vaginitis.
doi:10.1128/JCM.01537-13
PMCID: PMC3889753  PMID: 23985917
6.  A prospective study of genital infections in a family-planning clinic. 1. Microbiological findings and their association with vaginal symptoms. 
Epidemiology and Infection  1990;104(1):47-53.
A prospective study of genital infection was conducted in four inner-city family-planning clinics. Fifteen per cent of routine attenders had symptoms and signs of vaginal infection and many more women attended primarily because of symptoms. Among the women with both signs and symptoms, 70% had positive laboratory findings, Trichomonas vaginalis, Candida albicans and bacterial vaginosis being equally prevalent. Measurement of vaginal pH in the clinic was the single most useful clinical finding for directing empirical therapy. Among patients with a discharge confirmed on examination and an abnormally high pH, 72% had either T. vaginalis or bacterial vaginosis. Neisseria gonorrhoeae was isolated from 4% of women with, and 1% of those without, symptoms. We believe that it is worthwhile to investigate patients presenting to family-planning clinics with vaginal symptoms. No single specimen was found ideal for all pathogens, a cervical swab is better for gonococci and also for T. vaginalis but a vaginal swab is needed for candida and bacterial vaginosis.
PMCID: PMC2271733  PMID: 2307184
7.  Epidemiologic Features of Vulvovaginal Candidiasis among Reproductive-Age Women in India 
Background. Vulvovaginal candidiasis is characterized by curd-like vaginal discharge and itching, and is associated with considerable health and economic costs. Materials and Methods. We examined the incidence, prevalence, and risk factors for vulvovaginal candidiasis among a cohort of 898 women in south India. Participants completed three study visits over six months, comprised of a structured interview and a pelvic examination. Results. The positive predictive values for diagnosis of vulvovaginal candidiasis using individual signs or symptoms were low (<19%). We did not find strong evidence for associations between sociodemographic characteristics and the prevalence of vulvovaginal candidiasis. Women clinically diagnosed with bacterial vaginosis had a higher prevalence of vulvovaginal candidiasis (Prevalence 12%, 95% CI 8.2, 15.8) compared to women assessed to be negative for bacterial vaginosis (Prevalence 6.5%, 95% 5.3, 7.6); however, differences in the prevalence of vulvovaginal candidiasis were not observed by the presence or absence of laboratory-confirmed bacterial vaginosis. Conclusions. For correct diagnosis of vulvovaginal candidiasis, laboratory confirmation of infection with Candida is necessary as well as assessment of whether the discharge has been caused by bacterial vaginosis. Studies are needed of women infected with Candida yeast species to determine the risk factors for yeast's overgrowth.
doi:10.1155/2012/859071
PMCID: PMC3478712  PMID: 23118494
8.  Candidiasis (vulvovaginal) 
Clinical Evidence  2010;2010:0815.
Introduction
Vulvovaginal candidiasis is estimated to be the second most common cause of vaginitis after bacterial vaginosis. Candida albicans accounts for 85% to 90% of cases.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women? What are the effects of alternative or complementary treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women? What are the effects of treating a male sexual partner to resolve symptoms and prevent recurrence in non-pregnant women with symptomatic acute vulvovaginal candidiasis? What are the effects of alternative or complementary treatments for symptomatic recurrent vulvovaginal candidiasis in non-pregnant women? What are the effects of treating a male sexual partner in non-pregnant women with symptomatic recurrent vulvovaginal candidiasis? What are the effects of treating asymptomatic non-pregnant women with a positive swab for candidiasis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 61 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: alternative or complementary treatments; douching; drug treatments; garlic; intravaginal preparations (boric acid, nystatin, imidazoles, tea tree oil); oral fluconazole; oral itraconazole; treating a male sexual partner; and yoghurt containing Lactobacillus acidophilus (oral or vaginal).
Key Points
Vulvovaginal candidiasis is characterised by vulval itching and abnormal "cheese-like" or watery vaginal discharge. Vulvovaginal candidiasis is estimated to be the second most common cause of vaginitis after bacterial vaginosis. Candida albicans accounts for 85% to 90% of cases.Risk factors include pregnancy, diabetes mellitus, and systemic antibiotics. Incidence increases with the onset of sexual activity, but associations with different types of contraceptives are unclear.Recurrent symptoms are common, but are caused by candidiasis in only one third of cases.
Intravaginal imidazoles reduce symptoms of acute vulvovaginal candidiasis in non-pregnant women. Intravaginal imidazoles (butoconazole, clotrimazole, miconazole) reduce symptoms compared with placebo and all seem to have similar efficacy compared with each other. RCTs suggest that single-dose regimens may be as effective as multiple-dose regimens.Intravaginal imidazoles and oral fluconazole or itraconazole seem equally effective in treating acute attacks.
Intravaginal nystatin reduces symptoms compared with placebo, but we don't know how it compares with intravaginal imidazoles or oral fluconazole or itraconazole.
The benefits of other intravaginal treatments, to treat acute attacks or prevent recurrence, remain unclear, and some may be associated with serious adverse effects. We found no RCT evidence assessing intravaginal boric acid or tea tree oil.We found no RCT evidence assessing garlic or yoghurt, used intravaginally or orally.We found no RCT evidence on efficacy of douching, but it is associated with serious adverse effects such as PID and infections, endometritis, and ectopic pregnancy. Oral fluconazole and itraconazole are likely to be beneficial in preventing recurrence of infection. Treating the woman's male sexual partner does not reduce symptoms or prevent recurrence in the woman.
PMCID: PMC2907618  PMID: 21718579
9.  Circulating heat shock proteins in women with a history of recurrent vulvovaginitis. 
OBJECTIVE: Predisposing factors influencing recurrences of bacterial vaginosis (BV) or vaginitis from Candida remain unidentified for most women. As a component of studies to determine host susceptibility factors to genital tract infections in women, we measured expression of the 60-kDa and 70-kDa heat shock proteins (hsp60 and hsp70, respectively) in the circulation of women with or without a history of recurrent BV or candidal vaginitis and with or without a current lower genital tract infection. Heat shock protein expression is associated with a down-regulation of pro-inflammatory immune responses that would inhibit microbial infection. METHOD: The investigators measured hsp60 and hsp70, antibodies to these proteins, the pro-inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha), and the anti-inflammatory cytokine interleukin-10 (IL-10) in sera by ELISA. The study population consisted of 100 women who attended a gynecology clinic in Campinas, Brazil. Of those, 55 had a history of recurrent vulvovaginitis (RV), while 45 were controls with no such history. Only women who were asymptomatic for at least 1 month were studied. RESULTS: Although all were asymptomatic, clinical and microbiological examination revealed that five of the women with a history of RV and two controls had a current candidal vaginal infection; 16 RV patients and 12 controls had BV; and six RV patients had both BV and candidiasis. Twenty-eight RV patients and 31 controls had no clinical or microbiological detectable vaginal infection. Among the RV patients, hsp60 and hsp70 were more prevalent in those with current BV (40.9% and 50.0%, respectively) or a candidal infection (45.5% and 54.5%) than in women with no current infection (21.4% and 17.9%). In the women with no history of RV, BV was not associated with a high prevalence of hsp60 (8.3%) or hsp70 (8.3%). Interleukin-10 and TNF were not more prevalent in vaginitis patients or controls with a current candidal infection or BV than in uninfected subjects. CONCLUSION: The high prevalence of circulating hsp60 and hsp70 in women with a history of RV and current BV or vaginal candidiasis, but not in women with no history of RV, suggests that differences in heat shock protein induction may be related to susceptibility to recurrent vaginal infections.
doi:10.1002/(SICI)1098-0997(1999)7:3<128::AID-IDOG3>3.0.CO;2-I
PMCID: PMC1784728  PMID: 10371470
10.  Accuracy of the Clinical Diagnosis of Vaginitis Compared to a DNA Probe Laboratory Standard 
Obstetrics and gynecology  2009;113(1):89-95.
Objective
To estimate the accuracy of the clinical diagnosis of the three most common causes of acute vulvovaginal symptoms (bacterial vaginosis, candidiasis vaginitis, and trichomoniasis vaginalis) using a traditional, standardized clinical diagnostic protocol compared to a DNA probe laboratory standard.
Methods
This prospective clinical comparative study had a sample of 535 active duty United States military women presenting with vulovaginal symptoms. Clinical diagnoses were made by research staff using a standardized protocol of history, physical examination including pelvic examination, determination of vaginal pH, vaginal fluid amines test, and wet-prep microscopy. Vaginal fluid samples were obtained for DNA analysis. The research clinicians were blinded to the DNA results.
Results
The participants described a presenting symptom of abnormal discharge (50%), itching/irritation (33%), malodor (10%), burning (4%), or others such as vulvar pain and vaginal discomfort. According to laboratory standard, there were 225 cases (42%) of bacterial vaginosis 76 cases (14%) of candidiasis vaginitis, 8 cases (1.5%) of trichomoniasis vaginalis, 87 cases of mixed infections (16%), and 139 negative cases (26%). For each single infection, the clinical diagnosis had a sensitivity and specificity of 80.8% and 70.0% for bacterial vaginosis; 83.8% and 84.8% for candidiasis vaginitis; and 84.6% and 99.6% for trichomoniasis vaginalis when compared to the DNA probe standard.
Conclusion
Compared to a DNA probe standard, clinical diagnosis is 81-85% sensitive and 70- 99% specific for bacterial vaginosis, candida vaginitis, and trichomoniasis. Even under research conditions that provided clinicians with sufficient time and materials to conduct a thorough and standardized clinical evaluation, the diagnosis and therefore, subsequent treatment of these common vaginal problems remains difficult.
doi:10.1097/AOG.0b013e3181909f63
PMCID: PMC2745984  PMID: 19104364
11.  Reversible Deficiency of Antimicrobial Polypeptides in Bacterial Vaginosis  
Infection and Immunity  2006;74(10):5693-5702.
Bacterial vaginosis is a common condition associated with increased risk of sexually transmitted diseases, including human immunodeficiency virus infections. In contrast, vulvovaginal candidiasis has a much weaker association with sexually transmitted diseases. We found that vaginal lavage fluid from women with bacterial vaginosis is deficient in antimicrobial polypeptides and antimicrobial activity compared to fluid from healthy women or women with vulvovaginal candidiasis. Effective treatment normalized the concentrations of antimicrobial polypeptides in both bacterial vaginosis and in vulvovaginal candidiasis, suggesting that the abnormalities were a result of the diseases. Unlike in vulvovaginal candidiasis, the neutrophil attractant chemokine interleukin-8 (IL-8) was not increased in bacterial vaginosis, accounting for low concentrations of neutrophil-derived defensins in vaginal fluid. In organotypic cultures of human vaginal epithelium containing dendritic cells, treatment with Lactobacillus jensenii, a typical vaginal resident, induced the synthesis of IL-8 mRNA and the epithelial human β-defensin-2 mRNA, but a typical bacterial vaginosis pathogen, Gardnerella vaginalis, had no effect. When the two bacteria were combined, Gardnerella vaginalis did not interfere with the immunostimulatory effect of Lactobacillus jensenii. The loss of normal immunostimulatory flora in bacterial vaginosis is thus associated with a local deficiency of multiple innate immune factors, and this deficiency could predispose individuals to sexually transmitted diseases.
doi:10.1128/IAI.00524-06
PMCID: PMC1594936  PMID: 16988245
12.  Community based study of sexually transmitted diseases in rural women in the highlands of Papua New Guinea: prevalence and risk factors 
Sexually Transmitted Infections  1998;74(2):120-127.
OBJECTIVE: To estimate the prevalence of sexually transmitted diseases (STDs) and determine their risk factors/markers among a rural population of women in the highlands of Papua New Guinea. METHODS: Community based random cluster sample of women of reproductive age were interviewed and examined and had specimens collected for laboratory confirmation of chlamydial and trichomonal infection, gonorrhoea, syphilis, and bacterial vaginosis. RESULTS: Chlamydia trachomatis was detected in 26%, Trichomonas vaginalis in 46%, Neisseria gonorrhoeae in 1%, syphilis in 4%, pelvic inflammatory disease (PID) (diagnosed clinically) in 14%, and bacterial vaginosis in 9% of 201 women. 59% of the women had at least one STD. In a multivariate logistic regression analysis taking the clustered sampling into account, independent risk factors for chlamydial infection were age < or = 25 years, < four living children, visualization of yellow mucopurulent endocervical secretions on a white swab, and bacterial vaginosis. Being married to a man who did not have other wives was protective. For trichomonal infection, independent risk factors were having no formal education, infertility, more than one sexual partner in the previous 12 months, treatment for genital complaints in the previous 3 months, abnormal vaginal discharge detected on examination, and chlamydial infection. Similar levels of trichomonal infection were found in all age groups. Among married women, rates of infection correlated with their perception of their husband having had other sexual partners in the previous 3 months, and this relationship was significant for chlamydial infection among women over 25. CONCLUSION: STDs are a major problem in this population, with the risk factors varying by outcome. Current treatment regimens are inappropriate given the high prevalence of trichomonal infection, and the available services are inadequate. Effective interventions are required urgently to reduce this burden and to prevent the rapid transmission of HIV. 



PMCID: PMC1758105  PMID: 9634324
13.  Is Mycoplasma hominis a vaginal pathogen? 
* Deceased.
Objective: To evaluate the role of Mycoplasma hominis as a vaginal pathogen.
Design: Prospective study comprising detailed history, clinical examination, sexually transmitted infection (STI) and bacterial vaginosis screen, vaginal swabs for mycoplasmas and other organisms, follow up of bacterial vaginosis patients, and analysis of results using SPSS package.
Setting: Genitourinary medicine clinic, Royal Liverpool University Hospital.
Participants: 1200 consecutive unselected new patients who had not received an antimicrobial in the preceding 3 weeks, and seen by the principal author, between June 1987 and May 1995.
Main outcome measures: Relation of M hominis isolation rate and colony count to: (a) vaginal symptoms and with the number of polymorphonuclear leucocytes (PMN) per high power field in the Gram stained vaginal smear in patients with a single condition—that is, candidiasis, bacterial vaginosis, genital warts, chlamydial infection, or trichomoniasis, as well as in patients with no genital infection; (b) epidemiological characteristics of bacterial vaginosis.
Results: 1568 diagnoses were made (the numbers with single condition are in parenthesis). These included 291 (154) cases of candidiasis, 208 (123) cases of bacterial vaginosis, 240 (93) with genital warts, 140 (42) chlamydial infections, 54 (29) cases of trichomoniasis, and 249 women with no condition requiring treatment. M hominis was found in the vagina in 341 women, but its isolation rates and colony counts among those with symptoms were not significantly different from those without symptoms in the single condition categories. There was no association between M hominis and the number of PMN in Gram stained vaginal smears whether M hominis was present alone or in combination with another single condition. M hominis had no impact on epidemiological characteristics of bacterial vaginosis.
Conclusion: This study shows no evidence that M hominis is a vaginal pathogen in adults.
Key Words: bacterial vaginosis; vaginal pathogens; Mycoplasma hominis
doi:10.1136/sti.77.1.58
PMCID: PMC1758313  PMID: 11158693
14.  Bacterial vaginosis, vaginal flora patterns and vaginal hygiene practices in patients presenting with vaginal discharge syndrome in The Gambia, West Africa 
Background
Bacterial vaginosis (BV) – a syndrome characterised by a shift in vaginal flora – appears to be particularly common in sub-Saharan Africa, but little is known of the pattern of vaginal flora associated with BV in Africa. We conducted a study aimed at determining the prevalence of BV and patterns of BV-associated vaginal micro-flora among women with vaginal discharge syndrome (VDS) in The Gambia, West Africa.
Methods
We enrolled 227 women with VDS from a large genito-urinary medicine clinic in Fajara, The Gambia. BV was diagnosed by the Nugent's score and Amsel's clinical criteria. Vaginal swabs were collected for T vaginalis and vaginal flora microscopy, and for Lactobacillus spp, aerobic organisms, Candida spp and BV-associated bacteria (Gardnerella vaginalis, anaerobic bacteria, and Mycoplasma spp) cultures; and cervical swabs were collected for N gonorrhoeae culture and C trachomatis PCR. Sera were tested for HIV-1 and HIV-2 antibodies. Sexual health history including details on sexual hygiene were obtained by standardised questionnaire.
Results
BV prevalence was 47.6% by Nugent's score and 30.8% by Amsel's clinical criteria. Lactobacillus spp were isolated in 37.8% of women, and 70% of the isolates were hydrogen-peroxide (H202)-producing strains. Prevalence of BV-associated bacteria were: G vaginalis 44.4%; Bacteroides 16.7%; Prevotella 15.2%; Peptostretococcus 1.5%; Mobiluncus 0%; other anaerobes 3.1%; and Mycoplasma hominis 21.4%. BV was positively associated with isolation of G vaginalis (odds-ratio [OR] 19.42, 95%CI 7.91 – 47.6) and anaerobes (P = 0.001 [OR] could not be calculated), but not with M hominis. BV was negatively associated with presence of Lactobacillus (OR 0.07, 95%CI 0.03 – 0.15), and H2O2-producing lactobacilli (OR 0.12, 95% CI 0.05 – 0.28). Presence of H2O2-producing lactobacilli was associated with significantly lower prevalence of G vaginalis, anaerobes and C trachomatis. HIV prevalence was 12.8%. Overall, there was no association between BV and HIV, and among micro-organisms associated with BV, only Bacteroides spp. and Prevotella spp. were associated with HIV. BV or vaginal flora patterns were not associated with any of the factors relating to sexual hygiene practices (vaginal douching, menstrual hygiene, female genital cutting).
Conclusion
In this population, BV prevalence was higher than in corresponding populations in industrialised countries, but the pattern of vaginal micro-flora associated with BV was similar. BV or vaginal flora patterns were not associated with HIV nor with any of the vaginal hygiene characteristics.
doi:10.1186/1471-2334-5-12
PMCID: PMC1083415  PMID: 15757510
15.  The Villain Team-Up or how Trichomonas vaginalis and bacterial vaginosis alter innate immunity in concert 
Sexually Transmitted Infections  2013;89(6):460-466.
Objectives
Complex interactions of vaginal microorganisms with the genital tract epithelium shape mucosal innate immunity, which holds the key to sexual and reproductive health. Bacterial vaginosis (BV), a microbiome-disturbance syndrome prevalent in reproductive-age women, occurs commonly in concert with trichomoniasis, and both are associated with increased risk of adverse reproductive outcomes and viral infections, largely attributable to inflammation. To investigate the causative relationships among inflammation, BV and trichomoniasis, we established a model of human cervicovaginal epithelial cells colonised by vaginal Lactobacillus isolates, dominant in healthy women, and common BV species (Atopobium vaginae, Gardnerella vaginalis and Prevotella bivia).
Methods
Colonised epithelia were infected with Trichomonas vaginalis (TV) or exposed to purified TV virulence factors (membrane lipophosphoglycan (LPG), its ceramide-phosphoinositol-glycan core (CPI-GC) or the endosymbiont Trichomonas vaginalis virus (TVV)), followed by assessment of bacterial colony-forming units, the mucosal anti-inflammatory microbicide secretory leucocyte protease inhibitor (SLPI), and chemokines that drive pro-inflammatory, antigen-presenting and T cells.
Results
TV reduced colonisation by Lactobacillus but not by BV species, which were found inside epithelial cells. TV increased interleukin (IL)-8 and suppressed SLPI, likely via LPG/CPI-GC, and upregulated IL-8 and RANTES, likely via TVV as suggested by use of purified pathogenic determinants. BV species A vaginae and G vaginalis induced IL-8 and RANTES, and also amplified the pro-inflammatory responses to both LPG/CPI-GC and TVV, whereas P bivia suppressed the TV/TVV-induced chemokines.
Conclusions
These molecular host–parasite–endosymbiont–bacteria interactions explain epidemiological associations and suggest a revised paradigm for restoring vaginal immunity and preventing BV/TV-attributable inflammatory sequelae in women.
doi:10.1136/sextrans-2013-051052
PMCID: PMC3746192  PMID: 23903808
TRICHOMONAS; VAGINAL MICROBIOLOGY; IMMUNOLOGY; BACTERIAL VAGINOSIS; WOMEN
16.  Sexually transmitted and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru 
Sexually Transmitted Infections  2006;83(2):142-146.
Objective
To determine prevalences and predictors of sexually transmitted and reproductive tract infections among men and women seeking care at pharmacies.
Methods
Men and women with urethral discharge or dysuria and vaginal discharge were enrolled at 12 central and 52 smaller pharmacies in Lima, Peru. All participants answered a questionnaire. Men provided urine for polymerase chain reaction (PCR) testing for Neisseriagonorrhoeae and Chlamydiatrachomatis, and for leucocyte esterase testing. Women provided self‐obtained vaginal swabs for PCR testing for N gonorrhoeae and C trachomatis, Trichomonas vaginalis culture and bacterial vaginosis and Candida.
Results
Among 106 symptomatic men, N gonorrhoeae and C trachomatis were detected in 34% and were associated with urethral discharge compared with dysuria only (odds ratio (OR) 4.3, p = 0.003), positive urine leucocyte esterase testing (OR 7.4, p = 0.009), less education (OR 5.5, p = 0.03), and with symptoms for <5 days (OR 2.5, p = 0.03). Among 121 symptomatic women, 39% had bacterial vaginosis or T vaginalis, and 7.7% had candidiasis. N gonorrhoeae and C trachomatis were detected in 12.4% of the women. Overall, 48.8% had one or more of these infections. No factors were associated with vaginal infection, and only symptoms of vaginal discharge for <5 days were associated with N gonorrhoeae and C trachomatis (OR 4.0, p = 0.02). The main reason reported for seeking advice at pharmacies by both men and women was trust in pharmacy workers.
Conclusions
Among men and women presenting to pharmacies with urethral and vaginal symptoms, rates of urethral and vaginal infections were comparable to those found in other clinical settings. Pharmacies can contribute to the care and prevention of sexually transmitted infection in developing countries.
doi:10.1136/sti.2006.022657
PMCID: PMC2598629  PMID: 16916881
17.  Evaluation of Association between Vaginal Infections and High-Risk Human Papillomavirus Types in Female Sex Workers in Spain 
ISRN Obstetrics and Gynecology  2012;2012:240190.
Background. Infection with and persistence of high-risk human papillomavirus (HR-HPV) are the strongest risk factors for cervical cancer. In addition, other genital microorganisms may also be involved in the progression of HPV-associated lesions. Objetive. To evaluate the association of the vaginal microbiota (Candida spp., Trichomonas vaginalis, and bacterial vaginosis) with HR-HPV infection in Spanish female sex workers (FSWs). Methods. This cross-sectional study involved 208 (FSWs; age, 18–49 years) who visited a sexually transmitted infection (STI) information and prevention center (SERGAS) between January 2010 and December 2011. Face-to-face interviews were carried out. Cervical and vaginal samples were examined for human papillomavirus (HPV), Trichomonas vaginalis, Candida spp., and microorganisms related to bacterial vaginosis (BV). Results. HR-HPV was found to be significantly associated with BV in FSWs with positive results for HPV16-related types (31, 33, 35, and 52). T. vaginalis was isolated in FSWs with the following HR-HPVs: 18, 45, 66, and 68. Candida spp. were isolated only in FSWs with HPV 18-positive infection. Conclusion. We demonstrate a significant prevalence of HR-HPVs in FSWs with disturbances in the vaginal microbiota.
doi:10.5402/2012/240190
PMCID: PMC3415090  PMID: 22900198
18.  STD rapid assessment in Rwandan refugee camps in Tanzania. 
Genitourinary Medicine  1997;73(1):33-38.
OBJECTIVE: To obtain baseline information on sexually transmitted diseases (STDs) in the Rwandan refugees camps in Tanzania, prior to establishment of STD services. SETTING: The largest camps of Rwandan refugees in the Ngara District of Tanzania (estimated population 300,000). The study was carried out in 8 days in August 1994. SUBJECTS AND METHODS: A rapid assessment technique was used to measure STD prevalences among: (i) 100 antenatal clinic attenders (ANC); (ii) 239 men from outpatient clinics (OPD); and (iii) 289 men from the community. Interviews (by questionnaire) and genital examination were performed for all participants; sampling for females included genital swabs for the the diagnosis of Neisseria gonorrhoeae (NG), Candida albicans (CA), Trichomonas vaginalis (TV), bacterial vaginosis (BV) and a blood sample for syphilis serology. Men provided urine samples which were screened for leucocytes using the leucocyte esterase (LE) dipstick; urethral swabs for Gram stain were taken from men with a reactive LE test and from those with symptoms or signs of urethritis. OPD males provided a blood sample for syphilis serology. RESULTS: All groups reported frequent experience with STDs and engaging in risky sexual behaviour prior to the survey. During the establishment of the camps, sexual activity was reportedly low. Over 50% of ANC attenders were infected with agents causing vaginitis (TV/BV/CA) and 3% were infected with NG. The prevalence of active syphilis was 4%. In the male outpatients, the prevalence of urethritis was 2.6% and of serological syphilis was 6.1%. Among males in the community, the prevalence of urethritis was 2.9% (the majority being asymptomatic infections). We noted frequent over-reporting of STD symptoms, unconfirmed clinically or biologically. CONCLUSIONS: STD case detection and management should be improved by training health workers in using the WHO syndromic approach, and through IEC campaigns encouraging attendance at clinics. Rapid epidemiological methods provide quick and useful information at low cost in refugee camps.
PMCID: PMC1195757  PMID: 9155553
19.  Unique Vaginal Microbiota That Includes an Unknown Mycoplasma-Like Organism Is Associated With Trichomonas vaginalis Infection 
The Journal of Infectious Diseases  2013;207(12):1922-1931.
Background. The prevalence of Trichomonas vaginalis infection is highest in women with intermediate Nugent scores. We hypothesized that the vaginal microbiota in T. vaginalis–infected women differs from that in T. vaginalis–uninfected women.
Methods. Vaginal samples from 30 T. vaginalis–infected women were matched by Nugent score to those from 30 T. vaginalis–uninfected women. Equal numbers of women with Nugent scores categorized as normal, intermediate, and bacterial vaginosis were included. The vaginal microbiota was assessed using 454 pyrosequencing analysis of polymerase chain reaction–amplified 16S ribosomal RNA gene sequences. The 16S ribosomal RNA gene sequence of an unknown organism was obtained by universal bacterial polymerase chain reaction amplification, cloning, and sequencing.
Results. Principal coordinates analysis of the pyrosequencing data showed divergence of the vaginal microbiota in T. vaginalis–infected and T. vaginalis–uninfected patients among women with normal and those with intermediate Nugent scores but not among women with bacterial vaginosis. Cluster analysis revealed 2 unique groups of T. vaginalis–infected women. One had high abundance of Mycoplasma hominis and other had high abundance of an unknown Mycoplasma species. Women in the former group had clinical evidence of enhanced vaginal inflammation.
Conclusions. T. vaginalis may alter the vaginal microbiota in a manner that is favorable to its survival and/or transmissibility. An unknown Mycoplasma species plays a role in some of these transformations. In other cases, these changes may result in a heightened host inflammatory response.
doi:10.1093/infdis/jit100
PMCID: PMC3654749  PMID: 23482642
Trichomonas vaginalis; vaginal microbiota; mycoplasmas; bacterial vaginosis
20.  Family planning services in developing countries: an opportunity to treat asymptomatic and unrecognised genital tract infections? 
Genitourinary Medicine  1997;73(6):558-560.
OBJECTIVE: To determine the prevalence of asymptomatic and unrecognised genital tract infections among women attending a family planning clinic in rural South Africa. METHODS: 189 consecutive women had genital samples taken to diagnose infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Candida albicans, Treponema pallidum, and HIV, and to diagnose bacterial vaginosis. RESULTS: Mean age was 25 years; 155 (82%) were unmarried, 156 (83%) were currently using contraception, and 41 (22%) reported having an STD treated in the preceding 12 months. Although none volunteered abnormal urogenital symptoms, 74 (39%) had at least one elicited by direct questioning. 119 women (63%) had at least one genital infection: N gonorrhoeae (eight; 4%), C trachomatis (14; 8%), T vaginalis (26; 14%), C albicans (56; 30%), active syphilis (15; 8%), HIV (44; 24%), and bacterial vaginosis (29; 15%). 49 women (26%) had multiple infections. Most infections (71; 60%) were asymptomatic. Symptomatic women failed to recognise and report their symptoms, and routine services failed to detect the infections. CONCLUSION: Prevalence of genital tract infection is high among these women, most infections are asymptomatic, and symptomatic infections are frequently not recognised. Women attending family planning clinics in such settings should be screened for syphilis and offered testing for HIV infection. Strategies to detect and treat other genital infections need to be developed.
PMCID: PMC1195948  PMID: 9582484
21.  Pattern of sexually transmitted diseases among pregnant women in Burkina Faso, west Africa: potential for a clinical management based on simple approaches. 
Genitourinary Medicine  1997;73(3):188-193.
OBJECTIVES: (1) To determine the prevalence of sexually transmitted diseases (STDs) in pregnant women in Burkina Faso. (2) To evaluate the potential of clinical management of STDs based on screening with clinical data and urine leucocyte esterase test (LET). METHODS: Cross sectional study among antenatal clinic attendees was conducted in 1994 in Ouagadougou and Bobo-Dioulasso, the two largest urban centres in Burkina Faso, where more than 94% of the pregnant women benefit from antenatal care at least twice during their pregnancy. Each woman selected underwent an interview, general and gynaecological examination. Genital samples were collected to confirm the presence of STD pathogens. Logistic regression analysis was done to identify models that predict (a) gonorrhoea and/or chlamydia, (b) trichomoniasis and/or bacterial vaginosis, (c) candidiasis. Sensitivity, specificity and positive and negative predictive values of these models were assessed using standard methods. RESULTS: All 645 consecutive pregnant women were enrolled in the two sites. Among these women 32.4% presented at least one STD. The major STDs were: trichomoniasis (14%), bacterial vaginosis (13%), recent syphilis (3.6%), chlamydial infection (3.1%), genital warts (3%), gonococcal infection (1.6%) and genital ulcer (0.8%). Prevalence of vaginal candidiasis was 14%. The use of a risk marker (length of relationship with regular sexual partner < 3 years), and the positivity +3 of the urine LET provided a sensitivity of 80% and a positive predictive value of 7% for the screening of gonococcal and/or chlamydial infection. If clinical signs and positivity of the urine LET were taken into account sensitivity and positive predictive value of trichomoniasis and/or bacterial vaginosis screening were 77% and 37%, respectively. Clinical signs and positivity of the urine LET showed a low sensitivity (23%) for screening vaginal candidiasis. CONCLUSIONS: The prevalence of STDs in pregnant women is high in urban Burkina Faso. Systematic screening combined with effective treatment should be included in antenatal care in the future. Urine LET, if associated with interview and clinical examination offers a simple, rapid and affordable tool for systematic screening of STDs in pregnant women. However, the proportion of overtreatments with proposed strategies will be high. Further studies are needed to develop and validate better algorithms with probably cheap laboratory tests.
PMCID: PMC1195819  PMID: 9306899
22.  Evaluation and Management of Vaginitis 
OBJECTIVE
To evaluate recent advances in our understanding of the clinical relevance, diagnosis, and treatment of vaginal infections, and to determine an efficient and effective method of evaluating this clinical problem in the outpatient setting.
DATA SOURCES
Relevant papers on vaginitis limited to the English language obtained through a MEDLINE search for the years 1985 to 1997 were reviewed.
DATA SYNTHESIS
Techniques that enable the identification of the various strains of candida have helped lead to a better understanding of the mechanisms of recurrent candida infection. From this information a rationale for the treatment of recurrent disease can be developed. Bacterial vaginosis has been associated with complications, including upper genital tract infection, preterm delivery, and wound infection. Women undergoing pelvic surgery, procedures in pregnancy, or pregnant women at risk of preterm delivery should be evaluated for bacterial vaginosis to decrease the rate of complications associated with this condition. New, more standardized criteria for the diagnosis of bacterial vaginosis may improve diagnostic consistency among clinicians and comparability of study results. Use of topical therapies in the treatment of bacterial vaginosis are effective and associated with fewer side effects than systemic medication. Trichomonas vaginalis, although decreasing in incidence, has been associated with upper genital tract infection. Therapy of T. vaginalis infection has been complicated by an increasing incidence of resistance to metronidazole.
CONCLUSIONS
Vaginitis is a common medical problem in women that is associated with significant morbidity and previously unrecognized complications. Research in recent years has improved diagnostic tools as well as treatment modalities for all forms of vaginitis.
doi:10.1046/j.1525-1497.1998.00101.x
PMCID: PMC1496957  PMID: 9613891
vaginitis; diagnosis; therapy; yeast vaginitis; bacterial vaginosis; trichomonas vaginitis
23.  Lower genital tract infections in HIV-seropositive women in India 
Objectives:
The presence of STD facilitates shedding of HIV and increases HIV-1 disease progression, possibly by increasing plasma viremia. Our aim was to study the presence of various associated Sexually transmitted disease/Reproductory tract infections in HIV-seropositive women in India.
Materials and Methods:
The study included 40 HIV-seropositive women attending the antiretroviral therapy (ART) clinic at Lok Nayak Hospital. An informed consent was taken from all subjects. All cases were subjected to detailed gynecological examination and two types of swabs, i.e., a vaginal swab and a cervical swab were taken for STD/RTIs evaluation. The vaginal swabs were used for preparation of wet mount and KOH mount for diagnosis of trichomoniasis and candidiasis; to make a vaginal smear for Gram staining to diagnose bacterial vaginosis (BV) as per Nugent's criteria; for culture of aerobic bacteria and Candida spp. The cervical swab was used for isolation of Neisseria gonorrhoeae by culture and for detection of Chlamydia trachomatis antigen by Chlamydia microplate enzyme immunoassay kit (BIORAD). All data were analyzed using appropriate statistical tests.
Results:
All 40 cases were evaluated for the presence of STD/RTIs associated with HIV infection. The women belonged to the reproductive age group (15-45 years) and majority (40%) of them were para 2. Most of the women (14, 35%) were in World Health Organization (WHO) stage I and maximum number (28, 70%) had their CD4 cell count more than 200 cells/ml. There was no significant correlation between WHO stage of HIV-seropositive women and their CD4 cell count (P=0.092). Out of 40 cases, 15 (37.5%) were on ART with maximum cases (53.3%) in WHO stage III. The duration of ART was more than 6 months in 9 (60%) cases. The most common presenting complaint was vaginal discharge in women with WHO stage II and III and 27.5% women showed vaginitis on per speculum examination. Laboratory tests showed high prevalence of BV (30%), mixed infection (30%), and candidiasis (10%) among HIV-seropositive women (P<0.001 in both). Women with BV were mostly in WHO stage I (38.4%) and stage II (36.3%), while those with mixed infection were mainly in WHO stage III (36.3%) and stage IV (40%).Women with candidiasis were mainly in WHO stage III. C. trachomatis antigen was found only in one subject (prevalence 2.5%). Both WHO stage and CD4 cell count had no significant correlation with presence of BV (P=0.056 and 0.063, respectively) and candidiasis (P=0.492 and 0.530, respectively). Maximum number of patients on ART had mixed infection (53.3%), while most of the patients (36%) not on ART had BV. There was no significant association between duration of ART and the presence of vaginal infections.
Conclusions:
The prevalence of gynecological symptoms and RTIs in HIV-seropositive women is high enough to warrant routine gynecologic evaluation and RTI screening in these patients. However, larger studies and trials are needed to evaluate the effects of ART on these abnormalities as well as to choose the best screening tool in HIV-seropositive women.
doi:10.4103/0253-7184.85414
PMCID: PMC3195170  PMID: 22021972
HIV; lower genital tract infections; women
24.  PREVALENCE AND CORRELATES OF BACTERIAL VAGINOSIS AMONG YOUNG WOMEN OF REPRODUCTIVE AGE IN MYSORE, INDIA 
Purpose
Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge among women of childbearing age and is associated with STI/HIV and adverse birth outcomes. The objective of this study was to determine the prevalence and correlates of BV among young women of reproductive age in Mysore, India.
Methods
Between October 2005 and December 2006, 898 sexually active women of 15–30 years of age were enrolled from two reproductive health clinics in Mysore. The women underwent an interview followed by physical examination, HSV-2 serologic testing, endocervical culture for Neisseria gonorrhoeae, and vaginal swabs for diagnosis of BV, Trichomonas vaginalis infection and candidiasis. Statistical analyses included conventional descriptive statistics and multivariable analysis using logistic regression.
Results
Of the 898 women, 391 (43.5%) were diagnosed with ≥1 endogenous reproductive tract infection and 157 (17.4%) with ≥1 sexually transmitted infection. Only 863 women had Gram-stained vaginal smears available, out of which 165 (19.1, 95% confidence interval [CI]: 16.3%–22.2%) were found to have BV and 133 (15.4, 95% CI: 12.9%–18.3%) were in the ‘intermediate’ stage. BV was related to concurrent infections with T. vaginalis (odds ratio [OR] = 4.07, 95% CI: 2.45–6.72) and HSV-2 seropositivity (OR = 2.22, 95% CI: 1.39–3.53).
Conclusions
In this population, the prevalence of BV at 19% was relatively low. Coinfection with T. vaginalis, however, was common. BV was independently associated with concurrent T. vaginalis infection and partner’s alcohol use. Muslim women had reduced odds of BV as compared to non-Muslim women. Further research is needed to understand the role of T. vaginalis infection in the pathogenesis of BV and the sociocultural context surrounding the condition in India.
PMCID: PMC3625939  PMID: 18445948
Bacterial vaginosis; correlates; epidemiology; India; prevalence; sexually transmitted infections
25.  Throwing the dice for the diagnosis of vaginal complaints? 
Backround
Vaginitis is among the most common conditions women are seeking medical care for. Although these infections can easily be treated, the relapse rate is high. This may be due to inadequate use of the diagnostic potential.
Methods
We evaluated the misjudgement rate of the aetiology of vaginal complaints. A total of 220 vaginal samples from women with a vaginal complaint were obtained and analysed for numbers of total lactobacilli, H2O2-producing lactobacilli, total aerobic cell counts and total anaerobic cell counts including bifidobacteria, Bacteroides spp., Prevotella spp. Additionally, the presence of Atopobium vaginae, Gardnerella vaginalis, Candida spp. and Trichomonas vaginalis was evaluated by DNA-hybridisation using the PCR and Affirm VPIII Microbial Identification Test, respectively.
Results
The participating physicians diagnosed Bacterial vaginosis (BV) as origin of discomfort in 80 cases, candidiasis in 109 cases and mixed infections in 8 cases. However, a present BV, defined as lack of H2O2-lactobacilli, presence of marker organisms, such as G. vaginalis, Bacteroides spp. or Atopobium vaginae, and an elevated pH were identified in only 45 cases of the women examined. Candida spp. were detected in 46 cases. Interestingly, an elevated pH corresponded solely to the presence of Atopobium vaginae, which was detected in 11 cases.
Conclusion
Errors in the diagnosis of BV and candida vulvovaginitis (CV) were high. Interestingly, the cases of misjudgement of CV (77%) were more numerous than that of BV (61%). The use of Amsel criteria or microscopy did not reduce the number of misinterpretations. The study reveals that the misdiagnosis of vaginal complaints is rather high.
doi:10.1186/1476-0711-5-4
PMCID: PMC1395331  PMID: 16503990

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