Journal Article

Bacterial Vaginosis Associated with Increased Risk of Female-to-Male HIV-1 Transmission: A Prospective Cohort Analysis among African Couples

Celum, Connie, Delany, Sinead, Kapiga, Saidi, Hong, Ting, Donnell, Deborah, Bukusi, Elizabeth A., Cohen, Craig R., Lingappa, Jairam R., Ngayo, Musa O., Baeten, Jared M., Spiegel, Carol A.

2012

Overview

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. 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). 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. ClinicalTrials.com NCT00194519.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Acquired immune deficiency syndrome / Adult / Africa - epidemiology / AIDS / Clinical Trials as Topic / Cohort Studies / Development and progression / Disease transmission / Family Characteristics / Female / HIV / HIV infection / HIV Infections - complications / HIV Infections - epidemiology / HIV Infections - transmission / HIV Infections - virology / HIV Seropositivity - blood / HIV Seropositivity - complications / HIV Seropositivity - epidemiology / HIV Seropositivity - virology / HIV-1 - genetics / HIV-1 - physiology / Human immunodeficiency virus / Humans / Incidence / Infections / Male / Medical research / Medicine / Men / Physiological aspects / Prospective Studies / Risk Factors / RNA, Viral - blood / Sexually transmitted diseases / STD / Studies / Vagina - microbiology / Vagina - pathology / Vaginosis / Vaginosis, Bacterial - blood / Vaginosis, Bacterial - complications / Vaginosis, Bacterial - epidemiology