Risks for Bacterial Vaginosis in Lesbian & Bisexual Women JM Marrazzo, K Ringwood, KK Thomas University of Washington, Seattle WA jmm2@u.washington.edu

Marrazzo J Infect Dis 2002 Bradshaw J Infect Dis 2006 Background Most common Cause of vaginal symptoms prompting medical evaluation for vaginitis Cause of vaginitis >10% of women experience BV May cause 11% of preterm deliveries in U.S. Etiology not understood, but associated with douching, new male partner, unprotected sex in heterosexual women, sex between women Limited information on mediators for increased risk among WSW History of BV, shared vaginal sex toys: yes Recent male partner, no. of female partners: no Marrazzo J Infect Dis 2002 Bradshaw J Infect Dis 2006

Objective Define risks for BV in lesbian & bisexual women with attention to detailed sexual risk history

Methods Subjects recruited to research clinic 16-35 years Sex with woman (prior year) Recruited through ads (self-referred) and partners Computer-assisted self-interview (CASI) at enrollment Symptoms defined as change in vaginal fluid BV diagnosed by Amsel criteria Confirmation with Nugent criteria Associations between BV & subject characteristics estimated by Fisher’s exact test, chi-square, GEE Adjusted for enrollment of both partners currently in sexual relationship

HC = hormonal contraception Results Study Population 335 women enrolled, Oct 2003-Mar 2007 Median age 25 y; 96 (29%) with BV 40 % All Enrolled 30 20 22% nonwhite race 6% Hispanic ethnicity 6% douching in last year 40% sex with men in past year 91% any sexual activity in past 3 months 10 HC = hormonal contraception

Results Sexual Partners, Last 90 Days 323 (91%): any sex 276 (82%): recent female partners 33% new partner 80 (24%): recent male partners 10% new partner Of all 335, 40% with >1 male partner in last year % Sex of Partners

Results Sexual Partners, Last 90 Days % However, 40% of all 335 reported at least one male SP in last year N = 277 N = 80 No. of Partners Most reported 1 partner 22% - 34% reported >1 partner

Results Sexual Practices, Last 90 days % All Male Partner “Any” receptive vaginal or anal sex: penis, fingers, toy; IC = intercourse * For vaginal/anal intercourse & condom use, percentages refer to the 80 women reporting sex with men in last 90 days

Results Risk Factors for Prevalent BV: Univariate Analysis Demographics Prevalence of BV (%) OR (95% CI) Age >26 y 1.3 (0.8-2.1) Black race 2.0 (0.6-2.3) Current smoker 1.4 (0.8-2.5) P=0.17 P=0.22 P=0.33

Results Risk Factors for Prevalent BV: Univariate Analysis Demographics Prevalence of BV (%) OR (95% CI) Age <26 y 1.3 (0.8-2.1) Black race 2.0 (0.6-2.3) Current smoker 1.4 (0.8-2.5) P=0.17 P=0.22 P=0.33 BV-Related History OR (95% CI) P<0.001 Prior BV 1.6 (0.9-.2.7) Partner w/ BV hx 4.8 (2.5-9.2) Current symptoms 2.1 (1.2-3.6) P=0.007 P=0.07

Results Sexual Practices, Last 90 Days BV Prevalence (%) P=0.12 P=0.02 P=0.2 P=0.02 P=0.18 OR (95% CI) Share toy 1.9 (1.1, 3.3) Vaginal lubricant 2.1 (1.1, 4.1)

Behaviors, 90 days prior to visit Adjusted Risks for BV Behaviors, 90 days prior to visit OR 95% CI Vaginal lubricant use 1.86 0.94 - 3.68 Shared vaginal sex toy 1.70 0.96 - 3.01 Partner with BV history 4.53 2.59 - 7.93 Lubricant use and sex toy sharing were correlated (Spearman = 0.3) and thus assessed in separate MVA No association: age, race, smoking, HCU, douching, vaginal IC, receptive anal or oral sex, no. of or new partners

BV+ in Partners Enrolled 47 Partnerships Enrolled Both BV- 22 BV+/BV- 5 Both BV+ 20 rom the grant:  47 partnerships entering the study:20 couples - both had BV22 couples - neither had BV5 couples - discordant. Degree of concordance for presence or absence of BV within couples higher than expected (P<0.001)

BV+ in Partners Enrolled Both BV- 22 (13) BV+/BV- 5 (11) Both BV+ 20 (24) rom the grant:  47 partnerships entering the study:20 couples - both had BV22 couples - neither had BV5 couples - discordant. Degree of concordance for presence or absence of BV within couples higher than expected (P<0.001)

Conclusions Distinct risks predict prevalent BV among lesbian & bisexual women Demographics, hygiene Not prominent in this largely white group with douching rare Sex Vaginal fluid exchange Vaginal lubricant Further study needed Intervention to prevent sexual transfer of vaginal fluid Risks for incident, persistent and recurrent BV Molecular description of partners’ vaginal flora Assessment of lubricant use on vaginal lactobacilli

Other components vary: chlorhexidine pH 5.8 - 6.1 Other components vary: chlorhexidine

Limitations Subjects were self-referred or referred by partners Limits on reproducibility, generalizability However, excellent retention and diverse sexual practices Though many reported sex with men, may not be generalizable to women who are only sexually active with men

Acknowledgements Study personnel Support Nancy Dorn Jim Hughes, CFAR Dana Varon Lauren Asaba Susan Heideke Emily Hancock Kathy Agnew Becca Hutcheson Support Jim Hughes, CFAR