Article Text

Sexually transmitted infections among HIV seropositive men and women
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1. Seth C Kalichman1,
2. David Rompa1,
3. Marjorie Cage1
1. 1Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, USA
1. Dr Kalichman, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA sethk{at}mcw.edu

## Abstract

Objectives: To determine the prevalence of identified STIs and recognised symptoms of STIs and their association with health status, substance use, and sexual risk behaviour in a sample of HIV seropositive men and women.

Methods: 223 men, 112 women, and five transsexual people living with HIV infection completed confidential surveys. Participants were recruited through community based services, community health clinics, and snowball (chain) recruitment techniques in Atlanta, GA, USA in December 1999.

Results: We found that (263) 78% of participants had been sexually active in the previous 3 months. For the entire sample, 42 (12%) participants reported an STI in the past 3 months and 40 (11%) experienced symptoms of an STI without indicating a specific diagnosis in that time. Gonorrhoea, chlamydia, syphilis, and newly diagnosed herpes simplex virus (HSV) were identified at similar rates among men, whereas trichomonas, gonorrhoea, and newly diagnosed HSV occurred most often in women. STIs were associated with substance use in men and women, with “crack” cocaine users having the greatest likelihood of an STI relative to non-crack users. STIs were also associated with continued practice of sexual risk behaviours.

Conclusions: This sample of people living with HIV-AIDS reported high rates of diagnoses and symptoms of STIs. There were significant associations between STIs, substance use, and continued high risk sexual practices in men and women. These findings support the need for studies that confirm prevalence of STIs using clinical laboratory tests.

• HIV
• sexual risk
• HIV transmission

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## Introduction

We report the prevalence and correlates of self reported sexually transmitted infections (STIs) in a sample of HIV infected men and women. HIV infection is most frequently transmitted through unprotected anal and vaginal intercourse with an HIV infected partner. In addition, individuals who are unaware of their own HIV infection unknowingly transmit the virus to others during unprotected sex acts. As many as one in three HIV infected people continue to practise unprotected anal and vaginal intercourse after knowing that they are HIV positive, and unprotected sex often occurs with unknown serostatus or known HIV negative partners.1–3 Several STI epidemics are well documented in populations at risk for HIV,4,5 suggesting that STIs may also be prevalent in HIV infected people who continue to practise sexual risk behaviours. In addition, previous research has shown rates of incident STIs in people living with HIV infection that vary from 15% to 25%, depending on time intervals and inclusion criteria.6–8 STIs are known to complicate the course of HIV disease progression and facilitate HIV transmission during unprotected sex acts.9,10 Estimating the prevalence of STIs in HIV seropositive men and women can therefore provide important information for screening people with HIV-AIDS for STIs, targeting and planning interventions to reduce the spread of HIV, and forecasting trends in HIV infections. Towards this end, we report the point prevalence of identified STIs as determined by self reporting in a community recruited sample of HIV infected men and women. We also examined demographic characteristics, health status markers, alcohol and other drug use, and sexual practices among HIV positive men and women with self reported STIs.

## Methods

### PARTICIPANTS

Study participants were 223 (66%) men, 112 (33%) women, and five (1%) transsexuals. Because of the small number of transsexuals who had not undergone male to female sexual reassignment, we combined these participants with males for all further analyses. All participants were fluent English speakers.

### PREVALENCE OF STIs

For the entire sample, 42 (12%) participants reported an STI in the past 3 months and 40 (11%) experienced symptoms of an STI without indicating a specific diagnosis in that time. Therefore, a total of 82 (24%) participants were defined as having an STI or symptoms of an STI in the previous 3 months. Rates of specific STIs and STI symptoms for men and women are shown in table 1. Among men, gonorrhoea, chlamydia, syphilis, and newly diagnosed HSV were the most commonly reported STIs. Among women, trichomonas, gonorrhoea, and newly diagnosed HSV were most commonly identified. Symptoms of STIs were also reported differentially for men and women, with men most often reporting painful urination and women most often reporting an unexplained genital discharge. Analyses showed that women were significantly more likely than men to report an STI or STI symptom in the previous 3 months, χ2 (df = 1, n = 340) = 12.27, p <0.001.

Table 1

STI diagnoses and symptoms among men and women living with HIV-AIDS

Comparisons of people reporting a recent STI, people who were sexually active but not reporting an STI, and people who were not sexually active on demographic and health status characteristics showed significant differences for years of education, F (2, 336) = 3.9, p <0.05, and age, F (2,336) = 8.1, p <0.001. Planned comparisons showed that people with STIs were less educated than their sexually active counterparts and younger than people who were not sexually active. Among men and women there were also differences between groups in incomes under \$20 000 per year, but the differences were small and of limited practical significance. No other differences between groups were significant (see table 2).

Table 2

Demographic and health characteristics of men and women living with HIV-AIDS and diagnoses or symptoms of an STI in the past 3 months

### SUBSTANCE USE AND STIS

Analyses showed that men who had recently had an STI were significantly more likely to have used powder forms of cocaine, χ2 (df = 4, n = 223) = 13.7, p <0.01, crack cocaine, χ2 (df = 4, n = 223) = 14.3, p <0.01, and use of any non-alcoholic drug in the past 3 months, χ2 (df = 2, n = 224) = 10.1, p <0.01, compared with men who did not have an STI. Among women, having had an STI was not associated with the use of any single type of drug, although women who reported a recent STI were significantly more likely to have used non-alcoholic drugs in the past 3 months, χ2 (df = 2, n = 112) = 22.9, p <0.01. Collapsing across sexes, people with a recent STI were significantly more likely to use powder forms of cocaine, χ2 (df = 4, n = 335) = 13.9, p <0.01, crack cocaine, χ2 (df = 4, n = 337) = 16.9, p <0.01, and any non-alcoholic drug, χ2 (df = 2, n = 336) = 11.6, p <0.01, compared with people who did not have an STI (see table 3). When all of the individual substance use variables were included in a multiple logistic regression analysis, only use of crack cocaine predicted having had an STI, OR = 1.6, 95% CI = 1.1–2.6.

Table 3

Substance use among men and women living with HIV-AIDS and diagnoses/symptoms of an STI in the past 3 months

### SEXUAL RISK BEHAVIOURS

Analyses showed that men who had recently had an STI engaged in significantly more unprotected vaginal intercourse, t (226) = 2.9, p <0.01, significantly more unprotected anal intercourse, t (226) = 2.2, p <0.05, and significantly less condom use during anal intercourse, t (95) = 1.97, p <0.05, than men who did not have an STI. For women, analyses failed to show any significant differences between women who had an STI and women who did not have an STI in the past 3 months on any of the sexual risk behaviours. Collapsing across sexes, people with a recent STI reported significantly more unprotected vaginal intercourse, t (336) = 3.3, p <0.001, more condom protected vaginal intercourse, t (337) = 2.2, p <0.05, more total acts of vaginal intercourse, t (337) = 3.5, p <0.01, and significantly less condom use during anal intercourse, t (104) = 2.2, p <0.05, than people who did not have an STI (see table 4).

Table 4

Sexual practices among men and women living with HIV-AIDS and diagnoses or symptoms of an STI in the past 3 months

## Discussion

This study found that 12% of HIV infected people reported having an STI in the previous 3 months and an additional 11% reported symptoms possibly indicating an STI without an STI diagnosis. This point prevalence estimate of STIs among men and women living with HIV-AIDS is, however, limited by the study reliance on self reported diagnoses and self reported symptoms. Undetected STIs are common, particularly among women, suggesting that our methodology may have underestimated the actual prevalence of STIs. Also, self reported STIs can be underestimated as a result of social response biases,11 suggesting that our results represent a lower bound point estimate of STI prevalence in people living with HIV-AIDS. The current study findings should therefore be considered preliminary and in need of confirmatory research using clinical and laboratory screening methods for diagnosing STIs. Another study limitation was our lack of information regarding recent use of antibiotics for treating and preventing opportunistic infections, as these treatments will also affect some STIs. In addition, our study was limited by our failing to identify the HIV status of participants' sex partners, a factor essential to estimating risks for new HIV infections.

Findings from the current study strongly indicate the need for confirmatory research using biological testing for STIs in community samples of people living with HIV-AIDS. Results showed that substance use, particularly crack cocaine use, might be a marker for STI risk in HIV positive people. Across sexes, individuals who had used crack cocaine in the previous 3 months were nearly twice as likely to have had an STI or symptoms of an STI relative to people who did not have an STI or symptoms. Our findings also indicated higher rates of unprotected vaginal intercourse, protected vaginal and anal intercourse, and less proportional use of condoms during anal intercourse among people living with HIV-AIDS who had an STI or STI symptoms. Consistent with previous research,3 36% of HIV infected people reported engaging in unprotected intercourse in the previous 3 months. Given the suggested risks for STIs in our sample as well as the risks for transmitting treatment resistant strains of HIV,13 there is a need for HIV prevention interventions targeted to people who are already known to be infected with HIV. Interventions that focus on reducing substance use, reinforcing consistent condom use, and enhancing motivation to practise safer sex should be targeted to sexually active people with HIV. Interventions for people already infected but continuing risk practices will probably prove more efficient and cost effective than interventions that only target masses of uninfected people.14

## Acknowledgments

The authors thank the AIDS Survival Project of Atlanta, James Austin, Webster Luke, Kari DiFonzo, Delores Simpson, Jeff Buckles, Florence Kyomugrsha, and Michael DiMarco for their assistance with data collection. National Institute of Mental Health (NIMH) Grant R01-MH57624 and Center Grant P30 MH52776 supported this research.

Contributors: SCK served as the principal investigator on this study, directing its design, implementation, data analyses, and manuscript preparation; DR served as project coordinator, developing the participant recruitment and sampling scheme, establishing, and implementing study protocols, and interpreting the study findings; MC served as project director, maintaining quality assurance, managing data collection activities, and conceptualising study results.

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