To the Editor:
The relations between HIV infection and other sexually transmitted diseases (STDs) are complex. 1 Some studies show that other STDs may enhance HIV infectiousness in men and women by increasing viral shedding in genital tract secretions. In their review, Rotchford et al. 2 combined data from four studies and concluded that HIV was not detected significantly more frequently in the genital secretions of HIV-infected persons with Chlamydia trachomatis infection than in the secretions of those without HIV. This report seeks to underscore and expand on the authors’ caveats, including problems in choosing appropriate comparison groups, gender of the participants, and methods for detecting chlamydia and HIV.
One of the four Rotchford et al. 2 studies assessed 106 men who, as specified by the study protocol, had dysuria, urethral discharge, or genital ulceration. 3 The nine men in the study who had nongonococcal urethritis were somewhat less likely than those without the disorder to be shedding HIV. However, the current authors believe this study should not be included in an analysis of chlamydial infection and HIV shedding because everyone in the comparison group had other STD syndromes, also potentially making them more likely to be shedding HIV. For instance, 73% of the men in the comparison group had gonorrhea, and those with gonorrhea accounted for 83% of those who were shedding HIV. Furthermore, in that particular study, specific chlamydial testing was not performed, so it should not be used to address the issue of chlamydial infection and HIV shedding.
Each of the remaining three studies involved women. The largest of these studies showed that female sex workers with chlamydial infection were three times more likely to be shedding HIV than those without chlamydia. 4 In the other two studies, HIV shedding was also somewhat more commonly detected among women with chlamydial infection than among those without chlamydia, although these differences were not statistically significant. 5,6 However, the results pooled from these three studies showed that chlamydial infection was significantly associated with HIV shedding (Mantel-Haenszel odds ratio, 1.85; 95% CI, 1.1–3.2;P = 0.02). There was not substantial heterogeneity in the results from these three studies (Breslow-Day test for heterogeneity, P = 0.3), but meta-analysis may not be appropriate because of differences in study populations and methods.
The current authors agree with the call of Rotchford et al 2 for additional high-quality studies to address this issue. In the meantime, screening, treatment, and prevention of STDs, including chlamydial infection, remain an important part of care for HIV-infected persons. 7
PETER H. KILMARX, MD*†
PHILIP A. MOCK, MAppStat* AND
WILLIAM C. LEVINE, MD, MSc†
1. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75: 3–17.
2. Rotchford K, Strum AW, Wilkinson D. Effect of coinfection with STDs and of STD treatment on HIV shedding in genital tract secretions. Sex Transm Dis 2000; 27: 243–248.
3. Moss GB, Overbaugh J, Welch M, et al. Human immunodeficiency virus DNA in urethral secretions in men: association with gonococcal urethritis and CD4 depletion. J Infect Dis 1995; 172: 1469–1474.
4. Ghys PD, Fransen K, Diallo M, et al. The associations between cervicovaginal HIV shedding, sexually transmitted diseases, and immunosuppression in female sex workers in Abidjan, Côte d’Ivoire. AIDS 1997; 11: F85–F93.
5. John GC, Nduati RW, Mbori-Ngacha D, et al. Genital shedding of human immunodeficiency virus type 1 DNA during pregnancy: association with immunosuppression, abnormal cervical or vaginal discharge, and severe vitamin A deficiency. J Infect Dis 1997; 175: 57–62.
6. Mostad SB, Overbaugh J, DeVange DM, et al. Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet 1997; 350: 922–927.
7. Centers for Disease Control and Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases: United States recommendations of the advisory committee for HIV and STD prevention. MMWR Morb Mortal Wkly Rep 1998; 47: 1–24.