1. Risk factors for Incident Trichomonas vaginalis among Women Recruited in RESPECT-2, an HIV Prevention Trial D Helms 1, D Mosure 1, T Peterman 1, C Metcalf 1,2, J Douglas, Jr. 1,3, CK Malotte 4, S Paul 5 1 Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, GA 2 Aurum Institute for Health Research, Johannesburg, South Africa 3 Denver Health, Denver Colorado 4 California State University, Long Beach, CA 5 New Jersey Department of Health and Senior Services, Trenton, NJ

2. Trichomonas vaginalis Most common non-viral STD 5 million new infections occurring in the US annually 50% of infected females are asymptomatic Associated with adverse birth outcomes: premature rupture of the membranes, pre-term delivery, and low birth weight May increase susceptibility to, or transmissibility of, HIV Treatment cures 90-95% of infections

3. Epidemiology of T. vaginalis Prevalence typically ranges from 5-10% in women in the general population Risk factors for prevalent trichomonas infection include: black race, history of previous STDs, sex workers, pregnancy, multiple partners, and drug use One incidence study has been conducted* One county in China In women aged >25 years Incidence rate of 1.1 per 100 person-years *Sex Trans Dis 1996; 415-424.

4. Objective  To determine risk factors associated with prevalent and incident trichomonas infection

5. Methods Data from an HIV-prevention counseling trial (RESPECT-2) 3 STD clinics in Long Beach, CA; Denver, CO; and Newark, NJ; 1999-2001 1507 women aged 15-39 years Screened for STDs (chlamydia, gonorrhea, trichomonas) at baseline, 3, 6, 9, and 12 months Wet mount or culture was used to test for trichomonas infection

6. Analysis Prevalent trichomonas infection  Stratified by demographic, behavioral, and clinical risk factors Incident trichomonas infection  New Infection –  Negative test at baseline and positive test at follow-up or  Positive test at least 14 days after treatment  for a baseline infection  Stratified by demographic, behavioral, and clinical risk factors Logistic regression was used to identify risk factors

7. Results 1507 women 1462 tested by wet mount or culture for T. vaginalis at baseline 1269 tested at least once in follow-up* *Average duration of follow-up = 364 days 190 (13%) prevalent infections 168 (13%) incident infections

8. New and Repeat Infections 190 positive 1462 women 62 repeat 1272 negative 108 new infections 121 (72%) asymptomatic Baseline Follow-up Total Incident Asymptomatic 168 total incident infections

9. Risk Factors for Prevalent and Incident Trichomonas Infection Characteristics Prevalent % (N) Incident % (N) Age (years) 15-19 7.2 (359) 10.6 (303) 20-24 13.9 (461) 11.1 (395) 25-29 13.3 (278) 11.3 (240) 30-34 6.9 (195) 16.9 (178) 35-39 17.8 (169)22.9 (153) Race/Ethnicity White 5.9 (307) 4.9 (268) Hispanic 6.5 (260) 6.1 (228) Other 7.6 (170) 6.5 (154) Black 19.6 (725)21.2 (619) Education < 12 years 16.2 (413) 17.6 (358) > 12 years 14.4 (992)14.6 (856)

10. Risk Factors for Prevalent and Incident Trichomonas Infection Characteristics Prevalent % (N) Incident % (N) Partners Past 3 Months 0 ▬ 10.7 (224) 1 11.4 (747) 10.1 (751) 2 13.7 (387) 18.9 (180) >3 15.9 (320) 23.6 (89) Sex for drugs/money 1 Yes 26.3 (95) 40.0 (30) No 12.1 (1359) 12.0 (990) Symptoms of Trich 2 Yes 7.5 (752) 22.1 (213) No 5.5 (710) 11.5 (1056) Chlamydia 2 Yes 21.5 (181) 36.8 (38) No 11.8 (1268) 12.3 (1169) Gonorrhea 2 Yes 22.7 (97) 38.5 (26) No 12.3 (1355) 12.4 (1187) 1 Ever exchanged sex for money or drugs 2 At time of trichomonas infection or at the last study interval

11. Multivariate analysis Trichomonas Infection Prevalent Incident Risk Factors AOR 95% C.I. AOR 95% C.I. Age (years) 15-19 1.0 - 1.0 - 20-24 2.2 (1.3-3.6) 1.1 (0.6-2.0) 25-29 2.3 (1.3-4.0) 1.3 (0.7-2.7) 30-342.4 (1.3-4.4) 1.8 (0.9-3.6) 35-392.6 (1.4-4.7) 2.9 (1.4-6.0) Black 3.0 (2.0-4.5) 3.9 (2.3-6.7) >12 years of education1.6 (1.1-2.3) 1.9 (1.2-3.0) Sex for drugs/money 1 2.0 (1.1-3.3) 2.6 (1.1-6.2) Partners past 3 months ▬ 2.4 (1.5-3.7) Symptoms 2 ▬ 2.4 (1.9-8.9) Chlamydia 2 3.7 (1.6-8.3) 4.1 (1.6-8.3) 1 Ever exchanged sex for money or drugs 2 At time of incident trichomonas infection or at the last study interval

12. Limitations Results reflect women in STD clinics RESPECT-2 was not designed to evaluate risk factors associated with trichomonas infection Possible misclassification of incident infections  Due to low sensitivity of wet mount or culture  Due to drug resistant infection

13. Conclusions (1) Trichomonas infection is a common infection  13% of women had a prevalent infection  13% of women had an incident infection High percentage of asymptomatic incident infection Similar risk factors for prevalent and incident infection:  Older age (>35 years), Black race, concurrent chlamydial infection, and sex for drugs/money Multiple partners and symptoms of trichomonas are risk factors for incident infection

14. Conclusions (2) Future studies might consider additional information regarding, contraceptive method and whether the women douched Unlike other STDs (gonorrhea and chlamydia), T. vaginalis was associated with older age in women Further investigation should be done to determine if routine screening in STD clinics would be beneficial The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention