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Intermediate vaginal flora is associated with HIV prevalence as strongly as bacterial vaginosis in a cross-sectional study of participants screened for a randomised controlled trial
  1. Fernand Aimé Guédou1,2,
  2. Lut Van Damme3,4,
  3. Florence Mirembe5,
  4. Suniti Solomon6,
  5. Marissa Becker7,
  6. Jennifer Deese3,4,
  7. Tania Crucitti8,
  8. Michel Alary1,2
  1. 1URESP, Centre de recherche FRSQ du CHA universitaire de Québec, Quebec, Canada
  2. 2Département de Médecine Sociale et Préventive, Université Laval, Quebec, Canada
  3. 3Family Health International, Durham, North Carolina, USA
  4. 4CONRAD, Arlington, Virginia, USA
  5. 5Department of Obstetrics & Gynaecology, Makerere University, Kampala, Uganda
  6. 6Y.R Gaitonde Center for AIDS Research and Education, Chennai, India
  7. 7Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
  8. 8Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium
  1. Correspondence to Michel Alary, URESP, Centre de recherche FRSQ du CHA universitaire de Québec, Hôpital Saint-Sacrement, 1050, Chemin Sainte Foy, Quebec G1S 4L8, Canada; malary{at}


Objective The authors analysed data from female sex workers screened prior to participation in a microbicide trial to examine the association between prevalent vaginal flora abnormalities and HIV infection, with special emphasis on the role of the intermediate vaginal flora (IVF) in this association.

Methods Data from the Kampala, Cotonou, Chennai and Mudhol/Jamkhandi sites were analysed. Participants were interviewed and provided blood for HIV and syphilis antibody testing, genital samples for the diagnosis of vaginal flora abnormalities (using Nugent score) and other reproductive tract infections. Log-binomial regression was used to estimate the HIV prevalence ratio (PR) in relation to IVF and bacterial vaginosis (BV).

Results Among 1367 women, BV, IVF and HIV prevalences were 47.6% (95% CI=45.0% to 50.3%), 19.2% (95% CI=17.1% to 21.2%) and 27.0% (95% CI=24.6% to 29.3%), respectively. In multivariate analysis, adjusting for study site, age, years of education, occupation, female sterilisation, oral sex, past history of sexually transmitted infection, gonorrhoea and candidiasis, IVF was significantly associated with HIV infection with a PR similar to that of BV (adjusted PR=1.56 (95% CI=1.22 to 1.98) and 1.48 (95% CI=1.20 to 1.84), respectively).

Conclusions Though the cross-sectional design of the study precludes directional interpretation of the findings, the data do suggest that IVF may be as important as BV in HIV acquisition. The authors recommend prospective research to better understand the association between IVF and HIV acquisition.

  • Bacterial vaginosis
  • intermediate vaginal flora
  • HIV
  • female sex workers
  • CONRAD Cellulose Sulphate Trial
  • Africa
  • AIDS
  • Chlamydia trachomatis
  • epidemiology (general)
  • microbicides
  • antiretroviral therapy
  • clinical care (general)
  • commercial sex
  • developing world
  • laboratory diagnosis
  • same-day testing
  • laboratory
  • self-sampling
  • vaginitis

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  • Funding The parent microbicide trial (randomised controlled trial of 6% Cellulose Sulphate Gel and the Effect on Vaginal HIV Transmission) was sponsored by CONRAD (VA, USA) and co-funded by the United States Agency for International Development (USAID) through agreement No HRN-A-00-98-00020-00 and the Bill and Melinda Gates Foundation grant No 655000.

  • Competing interests None.

  • Ethics approval The parent study (the microbicide trial) was approved by the institutional review boards (IRBs) of each participating centres. In addition, the use of the data for the present manuscript was approved by the IRB of Université Laval of Quebec (Quebec), Canada.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Most of the combined data from the multisite study have been published. However, few site-specific data have been published and each site still has the right to publish its data.