Investigating the prevalence of vaginitis pathogens in HIV infected and uninfected pregnant women In Durban, South Africa.

Abstract

BACKGROUND: Vaginitis in pregnancy significantly contributes to obstetric complications such as preterm labor. Human Immunodeficiency Virus (HIV) infection is thought to increase risk of acquiring vaginitis in pregnancy and vice versa. Currently, there are limited data on the prevalence of vaginitis pathogens in vaginal infections and uninfected pregnant women from Durban. This study compared the prevalence of bacterial vaginosis (BV), Candida spp. and Trichomonas vaginalis (T. vaginalis) across HIV infected and uninfected pregnant women, thereby contributing to the body of knowledge in this area. In addition, this study identified risk factors associated with HIV infection, BV, Candida species (spp). and T. vaginalis in the studied population. METHODS: This study was a sub-study of a larger study which enrolled 273 pregnant women from King Edward VIII hospital in Durban. For the larger study, data obtained from eligible women included; sociodemographic, sexual behavior and clinical data. All participants were tested for HIV as part of standard of care at the clinic and two self-collected swabs were obtained from each woman. Permission to obtain data on their HIV status was requested from each women. One vaginal swab was used to test for the presence of vaginal pathogens and the second swab was stored for future use. The BD Max vaginal assay was used to detect BV, T. vaginalis and Candida spp. from a single swab. The prevalence estimates for HIV, BV, T. vaginalis and Candida spp. were calculated using percentage frequencies. Univariate and multiple logistic regressions were used to assess risk factors for HIV status and vaginitis pathogens. All analysis were conducted using RStudio. RESULTS: Of the n=273 enrolled in the larger study, n=128 women provided permission to access data on their HIV statuses. Therefore, for the current study a sample size of n=128 was available for analysis. Of the n=128 women in this study, 52/128 tested positive for HIV resulting in a HIV prevalence of 40.6%. The most prevalent vaginal infection diagnosed in the study population was Candida spp. (73/ 128, 57%), followed by BV (61/ 128, 47.7%) and T. vaginalis (14/128, 10.9%). BV positivity increased the likelihood for HIV by >2-fold (OR: 2.91, 95% CI: 1.08 – 8.63, p= 0.042), being Candida positive increased risk for HIV by 4-fold (OR: 4.04, 95% CI: 1.52 – 11.68, p= 0.007) and testing positive for T. vaginalis increased risk for HIV by 10-fold (OR: 10.15, 95%

CI: 2.38 – 55.81, p= 0.018). Having 2-4 lifetime sex partners increased the likelihood of being HIV infected by 9-fold (OR: 9.78, 95% CI: 2.69 – 47.07, p= 0.001) and having >4 lifetime sex partners increased the likelihood of being HIV infected by 33-fold (OR: 33.88, 95% CI: 5.62 – 274.00, p< 0.001). In the adjusted analysis, not knowing if their partner had other partners, increased the risk of being BV positive by 4-fold (OR: 4.05, 95% CI: 1.58 -11.16, p=0.005) and alcohol consumption increased the risk of being BV positive by 4-fold (OR: 4.44, 95% CI: 1.54 -14.96, p=0.009). Having a current abnormal vaginal discharge and HIV infection were significantly associated with Candida infection (OR: 3.63, 95% CI: 1.45- 9.90, p=0.008), and (OR: 5.19, 95% CI: 1.98 – 15.21, p=0.001), respectively. Similarly, to Candida infection, having a current abnormal vaginal discharge increased the risk of T. vaginalis infection by 5-fold (OR: 5.37, 95% CI: 1.39 – 24.59, p=0.019) and HIV infection increased the risk of T. vaginalis infection by 23-fold (OR: 23.25, 95% CI: 4.52 – 174.17, p=0.001). CONCLUSION: In this study, behavioral factors played a significant role in the risk for contracting infections. It is imperative that women must first perceive themselves to be at risk for contracting infections before they can be motivated to reduce that risk. This can be accomplished by conducting future studies which administer a risk assessment tool to the women so that they can be made aware of actual risk versus perceived risk. Older age group (25-34 years) of pregnant women has also been identified to be at higher risk of HIV transmission, therefore this group should be mainly targeted for risk assessment and prompt HIV testing during pregnancy. Lastly, routine screening of BV, Candida & T. vaginalis is recommended during pregnancy, as many women in this particular study population were found to be co-infected with all three pathogens. The screening is highly recommended largely, due to the fact that vaginitis in pregnancy has been identified as a risk factor for HIV infection.