title: Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study.
abstract: OBJECTIVE
  The heterosexual spread of HIV-1 is occurring at different rates in different parts of the world. The transmission probability of HIV-1 per sexual contact is low, but may be greatly enhanced by several cofactors. Sexually transmitted diseases (STD), especially genital ulcers, may be such factors. So far, epidemiological evidence that other STD facilitate HIV-1 transmission is weak. The objective of this study was to determine whether treatable STD enhanced sexual transmission of HIV-1 in a cohort of female prostitutes in Kinshasa, Zaire.
  
  
  METHODS
  We conducted a nested case-control study of 431 initially HIV-1-negative women followed prospectively for a mean duration of 2 years (with monthly STD check-ups and 3-monthly HIV-1 serology). Cases (seroconverters, n = 68) were compared with controls (women who remained HIV-1-negative, n = 126) for incidence of STD and sexual exposure during the presumed period of HIV-1 acquisition.
  
  
  RESULTS
  The annual incidence of HIV-1 in this cohort was 9.8%. Seroconverters were younger than HIV-1-negative women (mean age, 24.6 versus 26.8 years; P = 0.04). During the period of HIV-1 acquisition, cases had a much higher incidence of gonorrhoea, chlamydial infection and trichomoniasis, and engaged in unprotected sex with clients and partners more frequently than controls. After controlling for sexual exposure by multivariate analysis, adjusted odds ratios for seroconversion were 4.8 [95% confidence interval (CI), 2.4-9.8] for gonorrhoea, 3.6 (95% CI, 1.4-9.1) for chlamydial infection and 1.9 (95% CI, 0.9-4.1) for trichomoniasis. Genital ulcers were more frequent in cases than controls, but much less common than other STD.
  
  
  CONCLUSIONS
  Non-ulcerative STD were risk factors for sexual transmission of HIV-1 in women, after controlling for sexual exposure. Because of their high prevalence in some populations, non-ulcerative STD may represent a considerable population-attributable risk in the transmission of HIV-1 worldwide. The identification of treatable STD as risk factors for HIV-1 transmission offers an important additional strategy for the prevention of HIV/AIDS.
authors.affiliation: Projet SIDA, Kinshasa, Zaire.
authors.forename: M
authors.initials: M
authors.lastname: Laga
authors.forename: A
authors.initials: A
authors.lastname: Manoka
authors.forename: M
authors.initials: M
authors.lastname: Kivuvu
authors.forename: B
authors.initials: B
authors.lastname: Malele
authors.forename: M
authors.initials: M
authors.lastname: Tuliza
authors.forename: N
authors.initials: N
authors.lastname: Nzila
authors.forename: J
authors.initials: J
authors.lastname: Goeman
authors.forename: F
authors.initials: F
authors.lastname: Behets
authors.forename: V
authors.initials: V
authors.lastname: Batter
authors.forename: M
authors.initials: M
authors.lastname: Alary
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002690:Chlamydia Infections / Q000150:complications; D015331:Cohort Studies; D015023:Democratic Republic of the Congo / Q000453:epidemiology; D005260:Female; D006069:Gonorrhea / Q000150:complications; D015658:HIV Infections / Q000150:complications* / Q000453:epidemiology / Q000635:transmission*; D006679:HIV Seropositivity / Q000453:epidemiology; D015497:HIV-1; D006801:Humans; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D012307:Risk Factors; D011477:Sex Work; D012749:Sexually Transmitted Diseases / Q000150:complications*; D014245:Trichomonas Infections / Q000150:complications