Little is known about the incidence of anal HPV infection and related
sequelae, and factors associated with these outcomes, among adolescents who
are HIV-infected vs. uninfected but at-risk.
We analyzed data from a multisite U.S. study, the Reaching for
Excellence in Adolescent Care and Health Project. Adolescents aged
12–18 years who were behaviorally HIV-infected (n=319) or
HIV-uninfected but at-risk (n=177) were recruited. Incidence rates for anal
HPV, high-risk anal HPV, anogenital warts, and anal dysplasia were
calculated using Poisson modeling. Factors associated with these outcomes
were examined using Cox proportional hazards modeling.
Mean age at entry was 16.8 years; mean follow-up time for detection
of anal HPV was 22.4 months (SD 10.8). Most participants (76%) were
female; 70% were black non-Hispanic. HIV-infected (vs.
–uninfected) women had significantly higher incidence of anal HPV
(30 vs. 14 per 100 person-years; p=0.002), high-risk anal HPV (12 vs. 5.3
per 100 person-years; p=0.04), and anogenital warts (6.7 vs. 1.6 per 100
person-years; p=0.002) but not anal dysplasia. Although incidence rates were
higher for these outcomes among HIV-infected vs. -uninfected men, the
differences were not statistically significant. Among women, factors
associated with anal HPV and related sequelae differed by HIV status and
included biological, behavioral, and HIV-related factors. No factors were
associated with outcomes in men.
HIV-infected vs. -uninfected adolescent women had higher rates of
anal HPV and anogenital warts. Because HIV-infected youth are at increased
risk of these outcomes, enhanced HPV prevention efforts, such as
vaccination, are warranted for this group.
The vaginal microbiota may play a role in mediating susceptibility to sexually transmitted infections, including Trichomonas vaginalis (TV).
Data were analyzed from HIV-1 seronegative women participating in HIV Prevention Trials Network Protocol 035. At quarterly visits for up to 30 months, participants completed structured interviews and specimens were collected for genital tract infection testing. TV was detected by saline microscopy. BV was characterized by Gram stain using the Nugent score (BV=7-10; intermediate=4-6; normal=0-3 [reference group]). Cox proportional hazards models stratified by study site were used to assess the association between Nugent score category at the prior quarterly visit and TV acquisition.
In this secondary analysis, 2,920 participants from Malawi, South Africa, USA, Zambia and Zimbabwe contributed 16,259 follow-up visits. BV was detected at 5,680 (35%) visits and TV was detected at 400 (2.5%) visits. Adjusting for age, marital status, hormonal contraceptive use, unprotected sex in the last week and TV at baseline, intermediate Nugent score and BV at the prior visit were associated with an increased risk of TV (intermediate score: adjusted hazard ratio [aHR]=1.73, 95% confidence interval [CI] 1.21-2.19; BV: aHR=2.40, 95% CI 1.92-3.00). Sensitivity analyses excluding 211 participants with TV at baseline were similar to those from the full study population (intermediate score: aHR=1.54, 95% CI 1.10-2.14; BV: aHR=2.23, 95% CI 1.75-2.84)
Women with a Nugent score >3 were at an increased risk of acquiring TV. If this relationship is causal, interventions that improve the vaginal microbiota could contribute to reductions in TV incidence.
Bacterial vaginosis; Trichomonas vaginalis; vaginal microbiota; sexually transmitted disease acquisition; prospective cohort
We assessed the potential impact of internet partner notification (PN) among MSM and transgender women in Peru recently diagnosed with STD. Use of internet PN was anticipated for 55.9% of recent partners, including 43.0% of partners not currently expected to be notified, a 20.6% increase in anticipated notification outcomes.
Men Who Have Sex With Men; Transgender Women; Partner Notification; Sexually Transmitted Disease; Peru
We examined factors potentially related to providers’ self-reported human papillomavirus vaccine administration to female Medicaid enrollees among providers who consistently recommended vaccination. Some pronounced variability was observed in characteristics among providers who consistently administered vaccination, including provider age, race, and Vaccines for Children enrollment; patient/parent vaccine refusal; patient race/ethnicity; and patient volume.
HIV; home HIV testing; HIV self-testing; mathematical modeling; HIV epidemiology; OraQuick
The impact of syphilis reverse sequence screening has not been evaluated in community outreach. Using reverse sequence screening in neighborhoods identified with geographic information systems, we found that among 239 participants, 45 (19%) were seropositive. Of these, 3 (7%) had untreated syphilis, 33 (73%) had previously treated syphilis infection, and 9 (20%) had negative nontreponemal test results.
Accurate measurement of adherence to product use is an ongoing challenge in microbicide trials.
We compared adherence estimates using two applicator tests (a dye stain assay [DSA] and an ultraviolet light assay [UVA]), the Wisebag (an applicator container that electronically tracks container openings), and self-reported adherence (ability, frequency, and percent missed doses). Healthy, HIV-negative, non-pregnant US women aged 23 to 45 received a Wisebag and 32 applicators filled with placebo gel, were instructed to insert one applicator daily for 30 days, returned the Wisebag and all applicators, and completed an exit interview. Emptied applicators were tested by UVA and then DSA, and scored by two blinded readers. Positive and negative controls were randomly included in applicator batches.
Among 42 women enrolled, 39 completed the study. DSA and UVA yielded similar sensitivity (97% and 95%) and specificity (79% and 79%). Two participants had fully inoperable Wisebags and nine had partially inoperable Wisebags. The proportion of participants considered to have high adherence (≥80%) varied: 43% (Wisebag), 46% (UVA), 49% (DSA), and 62% to 82% (self-reports). For estimating high adherence, Wisebag had a sensitivity of 76% (95% CI, 50% to 93%) and a specificity of 85% (95% CI, 62% to 97%) compared with DSA. Although 28% of participants reported forgetting to open the Wisebag daily, 59% said it helped them remember gel use.
DSA and UVA performed similarly. Compared with these tests, self-reports overestimated and Wisebag underestimated adherence. Although Wisebag may encourage gel use, the applicator tests currently appear more useful for measuring use in clinical trials.
Wisebag; electronic adherence monitor; microbicide; applicator test; adherence
Applicator dye staining and ultraviolet (UV) light have been used in trials to measure adherence, but not in the setting of before and after sex gel dosing (BAT-24). This study was designed to determine if semen or pre-sex gel dosing impacts the sensitivity and specificity of a dye stain assay (DSA) for measuring vaginal insertion of placebo-filled applicators with BAT-24 dosing.
Healthy monogamous couples received Microlax®-type applicators filled with hydroxyethylcelluose placebo gel. Women were instructed to vaginally insert one dose of gel before and a second dose after sex and to return applicators within 48 hours after sex. Applicators were stained to detect semen followed by UV then DSA and scored by two readers. Positive and negative controls were randomly included in applicator batches.
Fifteen couples completed the study. Each female returned at least six applicators over a 30-day period. The sensitivity for insertion of post-sex applicators was higher for UV (97%) compared to DSA (90%) and the specificity was similar (≥96%). For pre-sex applicators, the sensitivity and specificity were higher for DSA (100%) compared to UV testing (87% sensitivity, 96% specificity). Among returned post-sex applicators, 95% tested positive by UV compared to 87% by DSA. Agreement between readers was significantly better on the pre-sex applicators for DSA than for UV and for post-sex readings agreement was less than half that for UV, although the results were not statistically significant.
Applicator tests are feasible for measuring adherence in trials with gel dosing before and after sex.
Approximately 45% of nongonococcal urethritis cases have no identified etiology. Novel bacteria recently associated with bacterial vaginosis (BV) in women may be involved. We evaluated the association of idiopathic nongonococcal urethritis and 5 newly described BV-associated bacteria (BVAB).
Heterosexual men 16 years or older attending a sexually transmitted disease clinic in Seattle, Washington, from May 2007 to July 2011 and negative for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum–biovar2 were eligible. Cases had urethral discharge or 5 or more polymorphonuclear leukocytes per high-power field in urethral exudates. Controls had no urethral discharge and less than 5 polymorphonuclear leukocytes per high-power field. Urine was tested for Atopobium spp., BVAB-2, BVAB-3, Megasphaera spp., and Leptotrichia/Sneathia spp. using quantitative taxon-directed polymerase chain reaction.
Cases (n = 157) and controls (n = 102) were of similar age, education, and income, and most were white. Leptotrichia/Sneathia spp. was significantly associated with urethritis (24/157 [15.3%] vs. 6/102 [5.9%], P = 0.03). BVAB-2 was more common in cases than in controls (7/157 [4.5%] vs. 1/102 [1.0%], P = 0.15), and BVAB-3 (n = 2) and Megasphaera spp. (n = 1) were only detected in men with urethritis, but these bacteria were found only in men who also had Leptotrichia/Sneathia spp. Atopobium spp. was not associated with urethritis. The quantity of bacteria did not differ between cases and controls. Among treated cases, doxycycline was more effective than azithromycin for clinical cure of men with Leptotrichia/Sneathia spp. (9/10 vs. 7/12, P = 0.16) and BVAB-2 (3/3 vs. 0/3, P = 0.10).
Leptotrichia/Sneathia spp. may be urethral pathogens or contribute to a pathogenic microbiota that can also include BVAB-2, BVAB-3, and Megasphaera spp. Doxycycline may be more effective than azithromycin against these newly identified bacteria.
This study aimed to provide a population-based estimate of human papillomavirus (HPV) seropositivity for women in a rural African context and to evaluate the impact of HPV serostatus on subsequent acquisition of HIVoutside a clinical setting.
A random sample of women participating in a longitudinal, population-based HIV survey combined with a case-control study.
Blood samples of women participating in a single round of population-based HIV surveillance (N = 1049) in a rural South African population were used to measure vaccine-preventable HPV seropositivity (types 6, 11, 16, and 18) in the general population in 2010. Using results from the repeat HIV surveys, a case-control analysis was then performed comparing HPV sero-status in samples taken from HIV sero-converting women (prior to infection with HIV) against samples from HIV-uninfected, sexually-active controls matched 1:1 according to 5-year age band (377:377). Unconditional multivariable logistic regression with multiple imputations was used to control for sociodemographic and behavioral variables associated with HIV acquisition.
Human papillomavirus seropositivity in the population-based sample of women was 20.8% (95% confidence interval [CI], 18.3–23.4), and HIV prevalence was 27.6% (95% CI, 24.9–30.4). In the case-control analysis, allowing for variables known to be associated with HIV incidence, HPV seropositivity was associated with nearly 2.5 times the odds of subsequent acquisition of HIV (adjusted odds ratio, 2.33 [95% CI, 1.61–3.39]; P < 0.001).
These results suggest that HPV vaccination before or soon after sexual debut could lower HIV infection risk. Randomized trials that quantify the impact of HPV vaccination in girls on the risk of acquiring HIV are urgently required.
The concern that adolescent girls who receive human papillomavirus (HPV) vaccine may be more likely to have sex (ie, sexual disinhibition) has been commonplace in media coverage, but this belief is not held by many parents of adolescent girls. Because no studies have addressed this topic for adolescent boys, we examined parents’ and their adolescent sons’ beliefs in sexual disinhibition occurring after boys receive HPV vaccine.
A national sample of parents of adolescent boys (n = 547) and their sons (aged 15–17 years; n = 176) completed online surveys in fall 2010. We used multi-item scales to measure parents’ and sons’ beliefs in sexual disinhibition after HPV vaccination. We used multivariate linear regression to identify correlates of beliefs in sexual disinhibition.
Less than a quarter of parents or sons agreed with statements suggesting that HPV vaccination leads to sexual disinhibition among adolescent boys (range, 20%–24%). Parents who had more liberal political affiliations (β = −0.11), had a daughter who had received HPV vaccine (β = −0.12), or had no daughter (β = −0.10) reported weaker beliefs in sexual disinhibition. Parents who reported higher anticipated regret if their sons got HPV vaccine and fainted (β = 0.18) indicated stronger beliefs in sexual disinhibition. Sons who perceived higher peer acceptance of HPV vaccination (β = 0.44) or were Hispanic (β = 0.21) had stronger beliefs in sexual disinhibition.
Most parents and sons did not believe that HPV vaccination leads to sexual disinhibition among boys. Understanding the characteristics of parents and sons who hold these beliefs may help inform efforts to increase HPV vaccine uptake among boys.
Successful development of topical rectal microbicides requires preclinical evaluation in suitable large animal models. Our previous studies have demonstrated the benefits of high resolution optical coherence tomography (OCT) to visualize subclinical microbicide toxicity in the sheep vagina. In the current study, we evaluated the potential application of colonoscopy and OCT to visualize and quantify the effects of topical products on sheep colorectal tissue as assessed by advanced imaging techniques.
Yearling virginal female sheep were treated rectally with a single 8mL dose of 0.2% BZK (benzalkonium chloride) solution or PBS control. Imaging was performed before and 30 minutes after treatment. Colonoscopy findings were evaluated based on mucosal disruption. OCT images were graded based on the integrity of the mucosal layer. Biopsies collected post-treatment were evaluated by histology for validation of OCT scoring.
Mucosal disruption was observed by colonoscopy in BZK-treated animals, while none was present in controls. In contrast to colonoscopy, high resolution in-depth OCT imaging provided visualization of the morphology of the mucosal layer and underlying muscularis, thus enabling detection of microscopic abnormalities. Noninvasive quantification of drug-induced injury after validation of the scoring system (Categories 1, 2, 3) showed increased scores after treatment with BZK (P<0.001), indicating mucosal injury.
High resolution OCT can be used as highly sensitive tool to evaluate rectal microbicide effects. Since the sheep rectum has both gross and microscopic similarities to the human, this model is a useful addition to current methods of rectal product toxicity.
rectal microbicide safety; sheep model; optical coherence tomography
A biomarker of unprotected receptive anal intercourse (RAI) could improve validity of sexual behavior measurement. We quantified prostate-specific antigen (PSA) from rectal swabs from men who have sex with men (MSM). One swab was PSA-positive. Using current methods, PSA is an inadequate biomarker of recent unprotected RAI in MSM.
MSM; Receptive anal intercourse; Prostate specific antigen (PSA); Measurement; Validity; biomarker
Sexually transmitted infection (STI) diagnosis following diagnosis of acute HIV infection (AHI) indicates ongoing high-risk sexual behavior and possible risk of HIV transmission. We assessed predictors of STI acquisition and the effect of time since care entry on STI incidence in AHI patients in care and receiving consistent risk-reduction messaging.
Data on incident gonorrhea, chlamydia, trichomoniasis, primary/secondary syphilis, demographic, and clinical risk factors were abstracted from medical charts for patients diagnosed with AHI and engaged in care. Poisson regression models using generalized estimating equations were fit to estimate incidence rates (IR), incidence rate ratios (IRR), and robust 95% confidence intervals (CI).
Among 185 AHI patients, 26 (14%) were diagnosed with ≥1 incident STI over 709.4 person-years; 46 STIs were diagnosed during follow-up (IR=6.8/100 person-years). The median time from HIV care entry to first STI diagnosis was 609 days (range=168–1681). Men who have sex with men (MSM) (p=0.03), a shorter time between presentation to medical care and AHI diagnosis (p=0.06), and STI diagnosis prior to AHI diagnosis (p=0.0003) were predictors of incident STI. STI IR >1 year after entering care was double that of patients in care ≤1 year (IRR=2.0 95% CI 0.8–4.9). HIV viral load was above the limits of detection within 1 month of 11 STI diagnoses in 6 patients (23.1%) (median=15,898 copies/mL, range=244–152,000 copies/mL).
Despite regular HIV care, STI incidence was high among this primarily young, MSM AHI cohort. Early antiretroviral initiation may decrease HIV transmission given ongoing risk behaviors despite risk-reduction messaging.
acute HIV infection; sexually transmitted infection; incidence; antiretroviral therapy; HIV care
Remnant specimen from 1,215 women screening for chlamydia/gonorrhea at four different venue types (STD clinics, home-test kit users, juvenile and adult detention) in Los Angeles, CA, were tested for T. vaginalis. Prevalence of T. vaginalis varied by screening population and concurrent chlamydia or gonorrhea was independently associated with T. vaginalis.
Trichomonas vaginalis; epidemiology; women
Violence against women has been associated with subsequent risky sexual behaviors and sexually transmitted infections. We explored whether sexual coercion or violence at first intercourse was associated with self-reported sexually transmitted infections (STIs).
Using nationally representative data from the 2006–2010 National Survey of Family Growth, we analyzed female respondents ages 18–44 (n=9,466) who answered questions on coercion at first intercourse (wantedness, voluntariness and types of force used) and STIs using logistic regression analyses. We explored degrees of coercion, which we label as neither, sexual coercion (unwanted or nonphysical force), or sexual violence (involuntary or physical force).
Eighteen percent of US women reported sexual coercion and 8.4% experienced sexual violence at first intercourse. Compared with women who experienced neither, the odds of reporting a STI was significantly greater for women who experienced sexual coercion (OR: 1.27, 95% CI: 1.01–1.60), after controlling for all variables. The association between sexual violence at first intercourse and STIs (OR: 1.20, 95% CI: 0.91–1.57) appeared to be attenuated by subsequent sexual violence.
Understanding that women who reported a variety of coercive sexual experiences are more likely to have contracted an STI may indicate a need to focus on the broader continuum of sexual violence to fully understand the impact of even subtle forms of violence on women’s health. In addition, focusing on subsequent sexual behaviors and other negative consequences remains important in order to improve the sexual health of women who have experienced coercive sexual intercourse.
violence; sexually transmitted infections; women; coercion; sexual assault
Female sex workers (FSWs) are less likely to use condoms with non-commercial male partners than clients. We compare non-commercial male partners who do and do not inject drugs in Tijuana and Ciudad Juárez, Mexico. Sexual risk behaviors were more prevalent among injectors, who could promote HIV/STI transmission in this region.
female sex workers; male partners; couples; sexually transmitted infections; injection drug use
Concurrent partnerships are a significant public health concern among men who have sex with men (MSM). This study describes the prevalence of concurrency and its association with serodiscordant/serostatus unknown unprotected anal or vaginal intercourse (SDUI) among MSM in New York City.
1,458 MSM completed a social and sexual network inventory about their male and female sex partners, including concurrency, in the last 3 months. Logistic regression identified factors associated with SDUI.
Median age was 29 years. 23.5% reported being HIV+. The men reported mean 3.2 male partners in last 3 months. 16.6% reported having recent SDUI. 63.2% described having concurrent sex partners (individual concurrency based on overlapping dates of relationships); 71.5% reported having partners whom they believed had concurrent partners (perceived partner concurrency); 56.1% reported that both they and their partners had concurrent partners (reciprocal concurrency). Among HIV+ men by self-report, having SDUI was positively associated with individual concurrency, any alcohol use during sex, having more male sex partners, and not having a main partner. Among self-reported HIV- men, having SDUI was positively associated with perceived partner concurrency, lower education level, any alcohol and drug use during sex, having more male sex partners, and having an anonymous partner.
Concurrency was common among MSM. The association of SDUI with individual and perceived partner concurrency, along with substance use during sex, having an anonymous partner, and having many sex partners likely further increases HIV acquisition and transmission risk among MSM. HIV prevention interventions should address concurrency among MSM.
Most persons diagnosed with HIV alter their sexual behavior in a way that reduces the risk of HIV transmission, but the durability of such behavior change is unknown.
We conducted annual anonymous cross-sectional surveys in randomly selected patients with appointments at a large, public hospital HIV Clinic in Seattle, Washington from 2005 to 2009. We used logistic regression to assess the association between time since HIV diagnosis and self-report of unprotected anal or vaginal intercourse (UAVI) with partners of negative or unknown HIV status (nonconcordant UAVI), and quantile regression to evaluate the association between time since HIV diagnosis and number of anal or vaginal sex partners.
We analyzed 845 surveys collected over 5 years. MSM had been diagnosed with HIV a mean of 12 (SD 7) years and non-MSM a mean of 11 (SD 6) years. Among 597 MSM, longer time since HIV diagnosis was associated with lower age-adjusted odds of reporting nonconcordant UAVI [(OR 0.96 (95% CI: 0.92 – 0.99)] and a lower age-adjusted number of sex partners (β coefficient −0.03, p=0.007). Among 248 women and heterosexual men, time since HIV diagnosis was not significantly associated with age-adjusted odds of nonconcordant UAVI [OR 0.99 (95% CI: 0.93 – 1.04)] or number of sex partners (β coefficient −0.01, p=0.48).
These results indicate that HIV transmission-associated behavior is relatively stable following the first year after HIV diagnosis. Our findings suggest that behavior change in the first year after HIV diagnosis, reported in other studies, is durable.
Sexual Behavior; HIV Infections/psychology; Homosexuality, male; Substance-Related Disorders/complications
The Centers for Disease Control and Prevention recommends at least annual HIV testing for men who have sex with men (MSM), but motivations for testing are not well understood.
We evaluated data from MSM testing for HIV at a community-based program in King County, Washington. Correlates of regular testing were examined using GEE regression models.
Between February 2004 and June 2011, 7176 MSM attended 12,109 HIV testing visits. When asked reasons for testing, 49% reported it was time for their regular test, 27% reported unprotected sex, 24% were starting relationships, 21% reported sex with someone new, 21% sought STI/hepatitis screening, 12% reported sex with an HIV-infected partner, 2% suspected primary HIV infection, and 16% reported other reasons. In multivariable analysis, factors associated with regular testing included having a regular healthcare provider and the following in the previous year: having only male partners, having ≥10 male partners, inhaled nitrite use, not injecting drugs, and not having unprotected anal intercourse with a partner of unknown/discordant status (p≤0.001 for all). Men reporting regular testing reported shorter intertest intervals than men who did not (median of 233 vs. 322 days, respectively; p<0.001).
Regular testing, sexual risk, and new partnerships were important drivers of HIV testing among MSM, and regular testing was associated with increased testing frequency. Promoting regular testing may reduce the time that HIV-infected MSM are unaware of their status, particularly among those who have sex with men and women or inject drugs.
HIV screening; men who have sex with men; testing frequency; reasons for testing