Interaction of Genital Abnormalities and Risk of HIV Acquisition among Women in Sero-Discordant Couples in Lusaka, Zambia Open Access

Ramachandran, Jyotsna Sita (2016)

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Background: Previous studies primarily focus on the effect of sexually transmitted infections (STIs) in HIV at-risk persons on sexual HIV acquisition risk; little consideration has been given to other non-STI genital ulcerative and inflammatory (GUI) abnormalities, or to the GUIs of HIV+ sexual partners. Information on the effect of multiple concurrent GUIs in both the donor and recipient on HIV transmission risk is scarce. This study examines the role of multiple GUIs, measured in both sexual partners, on women's HIV acquisition risk.

Methods: HIV serodiscordant heterosexual couples enrolled through couples' voluntary HIV counseling and testing (CVCT) were followed longitudinally from 1994-2012 with censoring at ART initiation, death/separation within the couple, or loss to follow-up. This analysis is restricted to couples where the man was the HIV+ partner (M+F-) and incident HIV infections were genetically linked to the study partner. HIV-negative partners were re-tested every three months for incident HIV infection. Indicators of GUI measured at study visits in both partners included: discharge, inguinal adenopathy (IA), bacterial vaginosis (BV), Candida, Trichomoniasis, ulcer, erosion/friability of the cervix/vagina, and smegma. Multivariable Cox models evaluated associations between GUIs and time to HIV infection, adjusting for age, viral load, and time enrolled.

Results: 207 infections occurred among 1,348 M+F- couples over 2,756 couple-years. Risk of infection in women was associated with women's: discharge (adjusted hazard ratio, aHR:1.97), Candida (aHR:1.72), ulcer (aHR:2.47), erosion/friability of the cervix/vagina (aHR:2.45), IA (aHR:2.13); and men's discharge (aHR:4.02), ulcer (aHR:1.55), IA (aHR:2.02), and smegma (aHR:1.81). Pairs of exposures significantly associated with HIV infection (versus having neither GUI) that had a synergistic effect on transmission risk were: BV and discharge (aHR:2.59) and Candida and discharge (aHR:3.21) (women); discharge and IA (aHR:4.98) (men); men and women with ulcers (aHR:4.78), and female ulcer with male smegma (aHR:5.34).

Conclusion: Increased routine screening/treatment of non-STI GUIs associated with HIV transmission is needed in both partners. Simultaneous screening/treatment for multiple GUIs is warranted since there is often clustering of these exposures, and many pairs act synergistically. Exploring low cost home-hygiene based methods of screening/treatment may be beneficial.

Table of Contents


Chapter I: Background/Literature Review 1

Chapter II: Manuscript 10

Title, Author, Abstract 10

Introduction 11

Methods 12

Results 17

Discussion 21

References 26

Tables 30

Table 1: Distributions and associations between genital abnormality predictors and HIV infection among M+F- couples, Lusaka, Zambia

Table 2: Combinational distributions of genital abnormality exposures by HIV infection outcome, M+F- couples, Lusaka, Zambia

Table 3: Adjusted hazard ratios for concurrent genital abnormalities and assessing for multiplicative interaction among M+F- couples in Lusaka, Zambia

Table 4: Population attributable fractions for genital abnormality exposures and pairs of genital abnormality exposures among M+F- couples in Lusaka, Zambia

Chapter III: Summary, Public health implications, and Future directions 36

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