braz
j
infect
dis
2
0
1
6;2
0(6):569–575
www.elsevier.com/locate/bjid
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Original
article
Anogenital
infection
by
Chlamydia
trachomatis
and
Neisseria
gonorrhoeae
in
HIV-infected
men
and
women
in
Salvador,
Brazil
Ana
Gabriela
Travassos
a
,b,∗
,
Eveline
Xavier-Souza
c
,
Eduardo
Netto
c
,
Eda
Vinhaes
Dantas
b
,
Maiara
Timbó
c
,
Isabella
Nóbrega
b
,
Tatiana
Haguihara
b
,
Júlia
Neumayer
c
,
Nathalia
Lisboa
c
,
Maria
Angela
Soidan
b
,
Fábio
Ferreira
d
,
Carlos
Brites
c
a
Universidade
Estadual
da
Bahia
(UNEB),
Salvador,
BA,
Brazil
b
Centro
Estadual
Especializado
em
Diagnóstico,
Assistência
e
Pesquisa
(CEDAP),
Salvador,
BA,
Brazil
c
Universidade
Federal
da
Bahia
(UFBA),
Salvador,
BA,
Brazil
d
Laboratório
Central
de
Saúde
Pública
Professor
Gonc¸alo
Moniz
(LACEN-BA),
Salvador,
BA,
Brazil
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
24
May
2016
Accepted
4
September
2016
Available
online
17
October
2016
Keywords:
HIV
Chlamydia
trachomatis
Neisseria
gonorrhoeae
Sexually
transmitted
infections
Anogenital
infections
a
b
s
t
r
a
c
t
Background:
Infections
caused
by
Chlamydia
trachomatis
and
Neisseria
gonorrhoeae
are
the
most
common
bacterial
sexually
transmitted
infections
throughout
the
world.
These
sexually
transmitted
infections
are
a
growing
problem
in
people
living
with
HIV/AIDS.
However,
the
presence
of
these
agents
in
extra
genital
sites,
remains
poorly
studied
in
our
country.
The
objective
of
this
study
was
to
estimate
the
prevalence
of
Chlamydia
trachomatis
and
Neisseria
gonorrhoeae
anal
and
genital
infection
in
people
living
with
HIV/AIDS
followed
in
a
reference
center
in
Salvador,
Brazil.
Methods:
Cross-sectional
study,
from
June
2013
to
June
2015.
Proven
HIV-infected
peo-
ple
attending
this
reference
center
were
invited.
Clinical
and
epidemiological
data
were
obtained
through
interview
with
standardized
form.
Chlamydia
trachomatis
and
Neisseria
gonorrhoeae
screening
was
performed
using
qPCR
(COBAS
4800
®
Roche).
Results:
The
frequency
of
positive
cases
of
Chlamydia
trachomatis
and
Neisseria
gonorrhoeae
was
12.3%
in
total,
9.2%
cases
amongst
women
and
17.1%
amongst
men.
We
found
14.0%
of
positive
cases
in
anus
and
3.1%
in
genital
region
in
men,
while
5.6%
and
3.6%,
in
women,
respectively.
Among
men,
anal
infection
was
associated
with
age
<29
years
(p
=
0.033),
report
of
anal
intercourse
(p
=
0.029),
pain
during
anal
intercourse
(p
=
0.028).
On
the
other
hand,
no
association
between
genital
infection
and
other
variables
were
detected
in
bivariate
analysis.
Among
women,
we
detected
an
association
between
Chlamydia
trachomatis
gen-
ital
infection
and
age
<29
years
(p
<
0.001),
younger
age
at
first
sexual
intercourse
(p
=
0.048),
pregnancy
(p
<
0.001),
viral
load
>50
copies/mL
(p
=
0.020),
and
no
antiretroviral
use
(p
=
0.008).
∗
Corresponding
author.
E-mail
address:
atravassos@uneb.br
(A.G.
Travassos).
http://dx.doi.org/10.1016/j.bjid.2016.09.004
1413-8670/©
2016
Sociedade
Brasileira
de
Infectologia.
Published
by
Elsevier
Editora
Ltda.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
570
b
r
a
z
j
i
n
f
e
c
t
d
i
s
.
2
0
1
6;2
0(6):569–575
Anal
infection
in
women
was
associated
with
age
<29
years
old
(p
<
0.001)
and
pregnancy
(p
=
0.023),
and
was
not
associated
with
report
of
anal
intercourse
(p
=
0.485).
Conclusion:
Missed
opportunities
for
diagnosis
in
extra
genital
sites
could
impact
on
HIV
transmission.
The
extra
genital
sites
need
to
be
considered
to
break
the
HIV
and
bacterial
sexually
transmitted
infections
chain-of-transmission.
©
2016
Sociedade
Brasileira
de
Infectologia.
Published
by
Elsevier
Editora
Ltda.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/
licenses/by-nc-nd/4.0/
).
Introduction
Chlamydia
trachomatis
(CT)
and
Neisseria
gonorrhoeae
(NG)
infections
are
the
most
common
bacterial
sexually
transmit-
ted
infections
(STI)
throughout
the
world.
1
These
infections
may
cause
complications
both
in
men
and
women,
such
as
epididymitis,
urethritis,
cervicitis,
pelvic
inflammatory
disease,
and
ectopic
pregnancy.
1,2
STI
in
extragenital
sites,
such
as
anus,
rectum,
and
pharynx,
are
an
increasing
cause
for
concern.
Recent
studies
show
increasing
reports
of
anal
intercourse
amongst
heterosexuals
and
lower
rates
of
con-
dom
use
in
anal
intercourse
compared
to
vaginal
intercourse.
3
Anorectal
mucosa
is
vulnerable
to
HIV
due
to
lack
of
appro-
priate
protective
humoral
immune
barrier
and
for
being
more
susceptible
to
traumatic
lesions
then
the
vaginal
mucosa.
4
In
addition,
possible
biological,
behavioral,
and
social
factors,
such
as
insufficient
knowledge
regarding
anorectal
STI
risks
and
anal
intercourse
to
please
the
partner
also
contribute
to
STI
infection.
5
The
low
percentage
of
diagnostic
screening
in
addition
to
inappropriate
treatment
maintain
the
bacterial
STI
chain-of-transmission,
thus
increasing
STI
and
HIV
transmission.
6
The
presence
of
CT
and
NG
infection,
especially
in
the
anorectal
region,
is
associated
to
the
increased
risk
of
HIV
infection.
In
people
living
with
HIV/AIDS
(PLHA),
CT
and
NG
infections
increase
the
genital
HIV
viral
load
(VL)
and
the
possibility
of
sexual
and
vertical
transmission
of
the
virus.
7
Despite
the
raise
of
the
HIV
epidemics
amongst
men
who
have
sex
with
men
(MSM)
highlight
the
role
of
unprotected
anal
intercourse
on
the
HIV
transmission,
the
role
of
this
practice
in
the
heterosexual
HIV
transmission
is
still
poorly
understood.
Although
studies
show
anorectal
prevalence
for
CT
in
women
(6.6–9.3%)
to
be
similar
to
that
of
MSM
(6.5–10.1%)
and
the
therapeutic
recommendations
for
infections
on
this
site
possibly
differ
from
those
in
the
urogenital
sites,
6,8,9
there
is
still
no
definition
regarding
the
systematic
investigation
for
CT
and
NG
in
extragenital
sites
in
heterosexual
women.
The
aim
of
this
study
was
to
estimate
the
prevalence
of
anorectal
and
genital
infection
by
C.
trachomatis
and
Neisse-
ria
gonorrhea
and
the
associated
risk
factors,
such
as
lifestyle
and
sexual
practices,
in
women
and
men
living
with
HIV/AIDS
receiving
care
in
a
reference
center
in
Salvador,
Brazil.
Material
and
methods
Patients
and
settings
This
was
a
cross-sectional
study
conducted
at
Centro
Espe-
cializado
em
Diagnóstico,
Assistência
e
Pesquisa
(CEDAP)
from
June
2013
to
June
2015.
CEDAP
is
the
state
reference
center
for
STI
and
HIV
in
Salvador,
Bahia,
Northeast
of
Brazil,
attending
approximately
60%
of
PLHA
in
the
state,
with
an
average
of
76
new
cases
of
HIV/AIDS
and
373
new
cases
of
STI
each
month.
The
health
center
is
staffed
with
infectious
disease
specialists,
and
other
medical
and
paramedical
professionals.
Irrespective
of
their
area
of
specialization
physicians
are
trained
to
deliver
care
for
patients
with
sexually
transmitted
diseases.
Confirmed
HIV-infected
patients
undergoing
treatment
with
the
gynecologist
and
proctologist
at
the
clinic
were
invited
to
participate
in
the
study,
regardless
of
their
signs
and
symptoms
of
STI.
Sexually
active
patients
regardless
of
age
were
assessed.
Patients
who
had
used
antibiotics
30
days
before
from
the
appointment,
and
women
with
genital
bleed-
ing
at
the
exam
were
not
included.
Pregnant
women
with
no
recent
obstetric
complications
were
also
included
in
this
study.
Laboratory
tests
The
CT
and
NG
screening
was
performed
using
qPCR
in
closed
system
–
In
vitro
Diagnostic
(IVD),
COBAS
4800
®
Roche,
using
COBAS
®
PCR
Media
Female
as
transport
for
the
endocervix
and
anorectal
specimens,
and
COBAS
®
PCR
Media
Urine
for
male
urine
samples.
The
samples
were
collected
according
to
the
manufacturer
instructions.
The
anorectal
samples
col-
lection
was
adapted
for
COBAS
®
PCR
Media
Female,
as
it
is
not
standardized
for
the
IVD
from
COBAS
4800
®
Roche
sys-
tem.
The
anorectal
samples
were
collected
through
the
swab
introduced
2–3
cm
after
anal
margin
and
it
was
done
in
360
◦
turn;
endocervix
samples
were
collected
by
gynecologist
dur-
ing
specular
exam;
and
urine
was
collected
by
the
patients
in
adequate
recipients.
The
samples
were
collected
during
a
medical
appointment
at
CEDAP
and
were
processed
at
the
Pro-
fessor
Gonc¸alo
Moniz
Central
Laboratory
of
Public
Health
of
Bahia
–
LACEN-BA.
All
patients
had
a
blood
sample
drawn
to
assess
HIV
viral
load
and
TCD4+/TCD8+
cells
count
at
the
time
of
the
appoint-
ment.
Lymphocyte
TCD4+/TCD8+
count
was
performed
by
flow
cytometry
(Facscalibur,
Becton
and
Dickinson,
California,
USA)
and
HIV
viral
load
was
quantified
using
PCR
Real
time
(Abbot
molecular,
Illinois,
USA)
Data
collection
Socio-demographic,
behavioral,
and
clinical
data
were
obtained
through
standardized
medical
interview.
Patients
were
scheduled
further
medical
appointment
one
month
after
sample
collection
for
delivering
tests
results
and
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a
z
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i
n
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e
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t
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.
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571
prescribing
treatment
of
the
identified
infections.
All
patients
signed
a
written
informed
consent.
This
study
was
approved
by
the
Ethics
Committee
of
the
Maternidade
Climério
de
Oliveira/Universidade
Federal
da
Bahia
(process
292,413).
Statistical
analyses
Data
analysis
were
performed
using
SPSS
20.0
(SPSS
Inc,
Chicago,
IL,
USA).
Chi-square
test
was
used
for
univariate
anal-
ysis
of
categorical
variables
like
ethnicity
(white
×
non-white),
marital
status
(single
×
married/stable
union),
schooling
(≤8
years
of
study
×
>8
years
of
study),
alcohol
intake,
tobacco
and
drug
use
(yes
×
no).
Continuous
variables
such
as
age,
age
at
first
intercourse,
number
of
partners,
and
time
since
HIV
diag-
nosis
were
analyzed
by
Student’s
t
test.
p-values
lower
than
0.05
were
considered
statistically
significant;
95%
confidence
intervals
(CI)
were
calculated
for
means
and
proportions.
Vari-
ables
with
p
≤
0.20
in
univariate
analysis
were
included
in
the
logistic
regression
backward
stepwise
model
for
multivariate
analysis.
For
women,
the
variables
in
the
regression
were:
age,
schooling,
pregnancy,
alcohol
use,
drugs
use,
pelvic
pain,
cer-
vicitis,
genital
discharge,
alcohol
before
sex,
anal
receptive
intercourse,
HAART
use,
HIV
viral
load.
For
men,
those
who
referred
no
anal
receptive
intercourse
were
excluded
from
the
logistic
regression
analysis
because
they
did
not
have
CT
or
NG
anal
infection.
Therefore,
the
variables
analyzed
were:
age,
ethnicity,
alcohol
before
sex,
pain
in
anal
intercourse,
genital
ulcer
and
painful
anorectal
exam.
Results
A
total
of
521
PLHA,
208
men
and
313
women
were
evaluated.
Of
those,
15
(2.9%)
men
who
did
not
collect
a
urine
sample
and
eight
(2.6%)
women
who
had
inadequate
anorectal
samples
were
excluded.
There
was
no
statistically
significant
differ-
ence
between
the
enrolled
and
excluded
patients.
The
final
sample
comprised
305
women
and
193
men.
The
overall
prevalence
of
any
CT
or
NG
infection
was
12.3%
(61/498),
9.2%
(28/305)
cases
amongst
women
and
17.1%
(33/193)
amongst
men.
The
overall
mean
age
was
37.0
years
(±10.5),
10.4%
(52/498)
self-reported
to
be
white,
38.6%
(192/498)
were
married
or
in
a
common-law
marriage,
and
73.5%
(366/498)
had
more
than
eight
years
of
regular
educa-
tion.
A
total
of
83.1%
(414/498)
were
on
antiretroviral
therapy,
but
37.0%
(165/446)
had
viral
load
above
40
copies/mL.
Some
significant
differences
between
genders
were
found
in
this
study
sample.
Men
were
younger,
mostly
single,
with
higher
education
and
family
income.
Alcohol,
tobacco
and
drug
use
were
more
frequently
declared
by
men,
as
well
as
higher
number
of
sexual
partners,
receptive
anal
sex,
and
his-
tory
of
STI,
as
seen
on
Table
1.
Amongst
women,
there
were
seven
cases
of
combined
CT
infection
(endocervix
and
anus).
Two
men
(6.1%)
had
both
anorectal
and
urine
positive
for
NG
infection,
and
one
(3.0%)
for
CT
infection
in
both
sites.
Regarding
the
investigated
site,
there
were
14.0%
(27/193)
of
positive
cases
in
anus
and
3.1%
(6/193)
in
genital
region
in
men,
while
5.6%
(17/305)
and
3.6%
(11/305)
cases
in
women,
respectively
(Table
2).
Clinical,
behavioral,
and
epidemiological
aspects
associ-
ated
with
the
presence
of
CT
and
NG
infection
in
genital
and
anorectal
areas
in
men
and
women
are
described
in
Table
3.
Among
men,
anorectal
infection
was
associated
with
age
<29
years
(p
=
0.033),
report
of
anal
intercourse
(p
=
0.029),
pain
during
anal
intercourse
(p
=
0.028),
and
painful
anorectal
exam
(p
=
0.022).
Only
men
who
referred
anal
intercourse
have
CT
and
NG
anal
infection.
After
logistic
regression,
the
vari-
ables
that
remained
significantly
associated
with
anorectal
infection
were
painful
anorectal
exam
(p
=
0.014,
OR-3.59,
95%
CI
1.29–9.95),
and
white
ethnicity
(p
=
0.018,
OR-3.85,
95%
CI
Table
1
–
Clinical
and
socio-demographic
characteristics
of
498
people
living
with
HIV/AIDS,
in
Salvador,
Brazil,
according
to
gender.
Characteristics
Men
(n
=
193)
Women
(n
=
305)
p-Value
Age
(years),
mean
(SD)
35.8
(9.9)
37.7
(10.8)
0.042
Age
at
sexual
debut
(years),
mean
(SD)
14.9
(3.4)
16.4
(3.5)
<0.001
Lifetime
number
of
sexual
partners,
median
(IQR)
30
(12–200)
5
(3–10)
<0.001
White
race,
n
(%)
30
(15.5)
22
(7.2)
0.003
Married/cohabitating
Marital
status,
n
(%)
46
(23.8)
159
(52.1)
<0.001
Educational
level
≥8
years,
n
(%)
170
(88.1)
196
(64.3)
<0.001
Monthly
household
income
≤2
minimum
wages,
n
(%)
a
102
(53.4)
252
(82.6)
<0.001
Alcohol
use,
n
(%)
144
(74.6)
166
(54.4)
<0.001
Tobacco
use,
n
(%)
42
(21.9)
29
(9.6)
<0.001
Drug
use,
n
(%)
52
(26.9)
43
(14.1)
<0.001
Alcohol
use
before
sex,
n
(%)
91
(47.2)
123
(40.9)
0.169
Drug
use
before
sex,
n
(%)
32
(16.6)
23
(7.5)
0.002
Transactional
sex,
n
(%)
19
(9.8)
28
(9.2)
0.805
Anal
receptive
intercourse,
n
(%)
167
(86.5)
191
(62.6)
<0.001
Previous
STI,
n
(%)
167
(86.5)
151
(49.5)
<0.001
Time
from
HIV
diagnosis
(months,
median
(IQR)
42.5
(10.5–121.7)
85.2
(32.8–136.8)
<0.001
ART
in
use,
n
(%)
159
(82.4)
255
(83.6)
0.722
Duration
on
ART
(days),
median
(IQR)
24.3
(2.0–82.6)
48.7
(3.0–121.7)
0.004
STI,
sexually
transmitted
infections.
The
numbers
do
not
always
add
up
the
total
because
of
missing
values.
a
Minimum
wage
≈$194.
572
b
r
a
z
j
i
n
f
e
c
t
d
i
s
.
2
0
1
6;2
0(6):569–575
Table
2
–
Prevalence
of
Chlamydia
trachomatis
(CT)
and
Neisseria
gonorrhoeae
(NG)
in
498
people
living
with
HIV/AIDS,
in
Salvador,
Brazil.
Chlamydia
trachomatis
n/N
(%)
Neisseria
gonorrhoeae
n/N
(%)
Total
a
n/N
(%)
Male
Anus
18/193
(9.3)
11/193
(5.7)
27/193
(14.0)
Urine
3/193
(1.6)
3/193
(1.6)
6/193
(3.1)
Female
Anus 16/305
(5.3)
2/305
(0.7)
17/305
(5.6)
Endocervix
11/305
(3.6)
0/305
(0.0)
11/305
(3.6)
a
Excluded
co-infections.
1.26–11.77).
On
the
other
hand,
no
association
between
genital
infection
and
other
variables
were
detected
in
univariate
anal-
ysis.
After
logistic
regression,
only
lifetime
sexual
partners
>3
(p
=
0.019,
OR-22.41,
95%
CI
1.67–305.94)
was
independently
associated
with
genital
infection.
Among
women,
there
was
an
association
between
CT
genital
infection
and
age
less
than
29
years
old
(p
<
0.001),
younger
age
at
first
sexual
intercourse
(p
=
0.048),
school-
ing
less
than
eight
years
(p
=
0.020),
pregnancy
(p
<
0.001),
viral
load
>50
copies/mL
(p
=
0.020),
and
no
antiretroviral
use
(p
=
0.008).
After
logistic
regression,
age
less
than
29
years
old
(p
=
0.010,
OR-8.25,
95%
CI
1.67–40.76),
schooling
less
than
eight
years
(p
=
0.012,
OR-8.29,
95%
CI
1.61–42.77),
pregnancy
(p
=
0.002,
OR-13.57,
95%
CI
2.63–69.94),
alcohol
use
before
sex-
ual
act
(p
=
0.025,
OR-14.54,
95%
CI
1.39–151.61),
and
cervicitis
(p
=
0.056,
OR-6.18,
95%
CI
0.96–39.97)
remained
statistically
significant.
Anorectal
infection
in
women
was
associated
with
age
less
than
29
years
old
(p
<
0.001)
and
pregnancy
(p
=
0.023),
but
it
was
neither
associated
with
report
of
anal
intercourse
(p
=
0.485)
nor
presence
of
symptoms.
Only
age
less
than
29
years
old
(p
=
0.001,
OR-10.54,
95%
CI
3.23–34.41)
remained
associated
with
infection
after
logistic
regression.
Discussion
A
high
prevalence
of
CT
and
NG
infection
in
PLHA
(12.3%)
was
found
in
this
study,
which
was
higher
among
men
(17.7%)
than
women
(9.2%).
Infections
were
more
prevalent
in
the
anorectal
(8.8%)
site
than
in
the
genital
(3.8%)
site.
Nowadays,
there
is
an
increase
in
anorectal
STI,
even
among
heterosexuals.
3,9,10
Some
guidelines
recommend
CT
and
NG
screening
in
extra-
genital
sites
on
MSM,
however
it
remains
undefined
for
heterosexuals.
11,12
Some
authors
suggest
focusing
the
screen-
ing
on
women
who
report
anal
intercourse.
10,13
The
lack
of
association
between
women
reporting
anal
intercourse
and
presence
of
anorectal
infection
in
our
study
corroborate
the
findings
of
a
study
conducted
in
Baltimore,
2014.
14
The
pres-
ence
of
bacterial
infection
with
or
without
symptoms
in
anus
and
rectum,
the
practice
of
anal
intercourse
in
the
general
population,
and
the
increasing
risk
of
HIV
transmission
rein-
force
the
need
for
appropriate
STI
diagnosis
and
treatment
on
anorectal
site.
In
this
study,
if
the
screening
had
been
only
urogenital,
CT
and
NG
infection
diagnoses
would
have
been
missed
in
88.9%
of
cases
in
men
and
58.8%
in
women.
Amongst
the
women
evaluated
on
this
study,
the
asso-
ciation
between
anorectal
and
genital
site
of
infection
and
younger
age
(p
<
0.001
on
both
cases)
and
pregnancy
(p
<
0.001
and
p
=
0.023)
highlights
the
need
for
screening
that
population
during
routine
follow-up.
These
associations
have
been
found
in
studies
with
women
living
with
HIV/AIDS,
and
in
the
gen-
eral
population,
15–17
but
it
is
not
yet
a
routine
in
most
services
in
Latin
America.
Recent
studies
detected
a
higher
chance
of
HIV
vertical
transmission
on
women
co-infected
with
NG
or
CT.
18,19
A
systematic
CT
and
NG
investigation
for
young
women,
pregnant
women,
and
women
living
with
HIV/AIDS
can
contribute
to
the
reduction
of
HIV
transmission,
and
be
an
effective
prevention
measure.
In
our
study,
the
prevalence
found
on
women’s
anorectal
region
was
5.3%
for
CT
and
0.7%
for
NG;
29.4%
of
women
with
infection
in
the
anorectal
region
denied
practice
of
anal
inter-
course.
There
are
few
reports
regarding
the
investigation
of
this
site
in
women
who
do
not
admit
anal
intercourse
or
symp-
toms
on
the
anal
region.
10
The
prevalence
rates
described
in
women
with
this
practice
vary
between
8.6%–12.7%
for
CT
and
1.0%–2.9%
for
NG
on
anorectal
sites.
6,14,20
We
found
an
associ-
ation
between
presence
of
infection
in
cervix
and
in
anorectal
site,
similar
to
other
authors.
13
Some
studies
highlight
the
possibility
of
self-inoculation
or
“translocation”
of
genital
site
infection.
14,21
Our
study
underscores
the
need
for
investi-
gating
the
anorectal
site
in
women
living
with
HIV/AIDS,
regardless
of
anal
intercourse
practice.
We
found
a
high
rate
of
anorectal
site
infection
among
men
(14.0%
positive
cases,
9.3%
for
CT
and
5.7%
for
NG),
similar
to
the
CT
and
NG
prevalence
found
in
other
studies
in
Brazil
(10.0%
and
2.5%),
USA
(7.9%
and
6.9%),
Netherlands
(10.1%
and
5.5%),
and
Russia
(7.3%
and
2.0%).
6,22–24
Only
men
who
referred
anal
intercourse
have
CT
and
NG
anal
infection.
The
char-
acteristics
of
this
population
are
similar
to
those
studied
in
other
countries,
with
multiple
sexual
partners,
receptive
and
insertive
anal
intercourse,
higher
education/socioeconomic
situation.
Despite
the
access
to
information
on
STI
prevention,
the
high
prevalence
indicates
a
high
exposure
to
NG
and
CT.
These
points
toward
an
urgent
need
for
reinforcing
preventive
measures,
such
as
condom
use,
education
on
sexual
transmis-
sion
risk,
and
prompt
access
to
bacterial
and
HIV
infections
post-exposure
prophylaxis.
b
r
a
z
j
i
n
f
e
c
t
d
i
s
.
2
0
1
6;2
0(6):569–575
573
Table
3
–
Uni variate
analysis
of
sociodemographic,
clinical
and
sexual
behavior-related
risk
factors
for
Chlamydia
trachomatis
(CT)
and
Neisseria
gonorrhoeae
(NG)
infection
in
498
people
living
with
HIV,
in
Salvador,
Brazil.
Men
Women
Urogenital
CT/NG
(n
=
6)
Anorectal
CT/NG
(n
=
27)
Endocervical
CT/NG
(n
=
11)
Anorectal
CT/NG
(n
=
17)
n
(%) p
OR
95%
CI
n
(%)
p
OR
95%
CI
n
(%)
p
OR
95%
CI
n
(%)
p
OR
95%
CI
Socio-demographic
Age
≤29
years
old
2
(3.8)
.669
1.32
0.24–7.45
12
(22.6)
.023
2.61
1.12–6.10
8
(10.8)
.001
9.21
2.38–35.71
11
(14.9)
.000
6.55
6.33–18.40
Single
4
(2.7)
.652
0.62
0.12–3.31
21
(14.3)
.832
1.11
0.42–2.95
5
(3.1)
.630
0.76
0.23–2.54
11
(6.9)
.285
1.73
0.63–4.82
White
ethnicity
2
(6.7)
.235
2.84
0.50–16.25
7
(23.3)
.108
2.18
0.82–5.72
1
(4.5)
.567
1.30
0.16–10.65
3
(13.6)
.114
3.03
0.80–11.48
Less
than
8
schooling
years 0
(0.0) 1.000 1.04 1.01–1.07 2
(8.7) .748 0.55
0.12–2.50
8
(7.3)
.020
5.10
1.32–19.63
7
(6.4)
.630
1.27
0.47–3.46
Monthly
income
≤2
MW
a
3
(2.9) 1.000
0.87
0.17–4.42
15
(14.7)
.809
1.11
0.49–2.51
11
(4.4)
.222
0.96
0.93–0.98
14
(5.6)
1.000
0.98
0.27–3.54
Pregnant
women
–
–
6
(18.8)
.000
12.37
3.53–43.31
5
(15.6)
.023
4.03
1.32–12.30
Alcohol
use
5
(3.5)
1.000
1.73
0.20–15.15
22
(15.3)
.376
1.59
0.57–4.45
3
(1.8)
.120
0.30
0.08–1.16
8
(4.8)
.530
0.73
0.27–1.95
Tobacco
use
2
(4.8)
.614
1.83
0.32–10.33
6
(14.3)
.962
1.02
0.39–2.73
0
(0.0)
.608
1.04
1.02–1.07
1
(3.4)
1.000
0.58
0.07–4.51
Drug
use
2
(3.8)
.661
1.37
0.24–7.71
9
(17.3)
.420
1.43
0.60–3.42
3
(7.0)
.191
2.38
0.60–9.35
1
(2.3)
.483
0.37
0.05–2.83
Sex-risk
behaviors
Lifetime
sexual
partners
>3
2
(66.6)
.092
18.20
1.41–235.34
2
(66.6)
.370
3.10
0.27–35-38
6
(3.0)
.409
1.66
0.50–5.57
9
(4.5)
.237
1.80
0.67–4.80
Irregular
condom
use
2
(4.8)
.614
1.83
0.32–10.32
7
(16.7)
.583
1.30
0.51–3.32
3
(3.0)
1.000
0.75
0.19–2.88
3
(3.0)
.194
0.41
0.12–1.47
Alcohol
before
sex
3
(3.3)
1.000
1.13
0.22–5.72
17
(18.7)
.076
2.11
0.91–4.89
1
(0.8)
.031
0.14
0.02–1.09
6
(4.9)
.631
0.78
0.28–2.16
Drug
before
sex
1
(3.1)
1.000
1.01
0.11–8.92
4
(12.5)
1.000
0.86
0.28–2.67
1
(4.3)
.584
1.24
0.15–10.11
1
(4.3)
1.000
0.76
0.10–5.97
Transactional
sex
0
(0.0)
1.000
1.04
1.01–1.07
2
(10.5)
1.000
0.70
0.15–3.22
2
(7.2)
.267
2.29
0.47–11.17
1
(3.6)
1.000
0.60
0.08–4.73
Anal
receptive
intercourse 5
(3.0)
.585
0.77
0.09–6.88
27
(16.2)
.029
0.84
0.78–0.90
4
(2.1)
.108
0.33
0.09–1.14
12
(6.3)
.485
1.46
0.50–4.26
Previous
STI 6
(3.6) 1.000 0.96
0.94–0.99
26
(15.6)
.136
4.61
0.60–35.53
6
(4.0)
.734
1.23
0.39–4.13
6
(4.0)
.228
0.54
0.19–1.49
Patient
complaints
Anal
fissure
b
2
(3.4)
1.000
1.12
0.20–6.31
10
(16.9)
.456
1.38
0.59–3.23
–
–
Pain
in
anal
intercourse
2
(4.0)
.676
1.28
0.23–7.23
12
(24.0)
.028
2.55
1.09–5.99
–
–
Dyspareunia
–
–
3
(4.5)
.706
1.36
0.33–5.62
5
(7.6)
.696
1.24
0.42–3.73
Genital
discharge
1
(16.7)
.178
7.12
0.70–72.72
1
(16.7)
.594
1.26
0.14–11.27
6
(5.5)
.188
2.21
0.66–7.43
9
(8.3)
.131
2.10
0.79–5.62
Genital
ulcer
1
(4.0)
.570
1.36
0.15–12.13
6
(24.0)
.122
2.21
0.79–6.16
0
(0.0)
1.000
1.04
1.02–1.06
0
(0.0)
.610
1.06
1.03–1.09
Pelvic
pain
0
(0.0)
1.000
0.58
0.07–4.66
3
(17.6)
.713
1.35
0.36–5.04
6
(5.5)
.188
0.58
0.18–1.85
4
(3.7)
.313
0.53
0.17–1.68
Anal
pain
2
(2.6)
1.000
0.74
0.13–4.14
14
(18.2)
.179
1.74
0.77–3.95
0
(0.0)
1.000
1.04
1.02–1.07
0
(0.0)
.614
1.06
1.03–1.09
Clinical
findings
Anal
fissure
b
1
(1.6)
.666
0.38
0.04–3.36
9
(14.1)
.914
1.05
0.44–2.51
–
–
Genital
discharge
1
(20.0)
.148
9.15
0.86–97.35
1
(20.0)
.533
1.56
0.17–14.49
5
(4.7)
.463
1.57
0.47–5.26
6
(5.6)
.985
1.01
0.36–2.81
Urethritis
1
(16.7)
.175
7.28
0.71–74.35
1
(16.7)
1.000
1.24
0.14–11.03
–
–
Cervicitis
–
–
3
(13.6)
.037
5.43
1.33–22.14
3
(13.6)
.114
3.03
0.80–11.48
Painful
anorectal
exam
b
0
(0.0) .585 1.04 1.00–1.07
9
(25.0)
.022
2.88
1.13–7.34
–
–
Painful
bimanual
exam –
–
2
(7.7)
.270
2.28
0.47–11.15
0
(0.0)
.382
1.07
1.04–1.11
Viral
load
.650
2.52
0.27–23.03
.626
0.79
0.31–2.01
.020
0.20
0.05–0.78
.051
0.36
0.12–1.04
≤40
cp/mL
4
(4.0)
12
(11.9)
3
(1.7)
6
(3.3)
>40
cp/mL
1
(1.6)
9
(14.5)
8
(7.8)
9
(7.8)
CD4+
≤500
cells/L
1
(1.7)
.653
0.42
0.05–3.84
10
(16.7)
.271
1.67
0.66–4.21
3
(3.6)
1.000
0.92
0.24–3.55
7
(8.4)
.178
1.99
0.72–5.55
No
ART
in
use
1
(2.94)
1.000
1.07
0.12–9.48
5
(14.7)
.894
0.93
0.33–2.66
5
(10.0)
.008
0.22
0.06–0.74
5
(10.0)
.136
0.44
0.15–1.32
CT/NG
indicates
chlamydia
and/or
gonorrhea
infection.
a
MW,
minimum
wage
≈$194.
b
Investigation
on
anal
fissure
and
painful
anorectal
exam
were
only
performed
by
the
proctologist
in
male
patients.