33–36 Other causes of genital inflammation also increase shedding of HIV, even in the absence of a known STI.37,38Neisseria gonorrhoeae has been shown to enhance HIV infection of CD4 cells39 and activated dendritic cells.40 Human papillomavirus (HPV) is receiving renewed attention in the mucosal immunity research. After years of being considered ‘the common cold’ of STI, the development of the HPV vaccine for the prevention of cervical

cancer has allowed for greater research in the area of genital mucosal Vemurafenib immunity. Much of this research has implications for studies involving HIV or risk of HIV. High-risk HPV reactivation has been shown to occur more commonly in HIV-infected women and is associated with an increase in genital shedding of HIV.41 HIV-positive serostatus is also associated with a delay in clearance of both high- and low-risk HPV.42 Disruption of the normal flora is well known to impact the delicate balance of the local genital immune system. Bacterial vaginosis has been associated with increased genital shedding of HIV RNA.43,44 Coleman et al.45 confirmed the importance of vaginal flora in a prospective study of vaginal health among HIV-infected Kenyan women. Antiretroviral naïve, HIV-infected women with normal CD4 counts had paired plasma and cervical wick samples collected for viral load measurement. Women with diminished Lactobacillus had a markedly

increased endocervical viral load, 15.8-fold (95% CI: EGFR inhibitor 2.0–123), compared to women with normal Lactobacillus levels (≥3+). Among women without

HIV, BV has been shown to significantly increase the risk of HIV acquisition, probably selleck chemicals as a function of disruption of natural immunity. In a large meta-analysis of 23 studies and including over 30,000 women, incident HIV was increased by BV, (relative risk = 1.6, 95% confidence interval: 1.2, 2.1).46 Other clinical characteristics that should be considered in studies of female genital tract mucosal immunity include age, body mass index, use of alcohol or substances, recent immunizations, use of systemic drugs (steroids, antiinflammatory agents, immune modulators, chemotherapy), gynecologic procedures (hysterectomy, curettage, biopsies), and vaginal practices. Vaginal practices include the very common practice internationally of vaginal douching. A prospective cohort study of female sex workers in Kenya showed that vaginal washing was associated with an increased risk of HIV acquisition, aHR, 1.47; 95% CI, 1.02–2.13.47 Clark et al.48 examined the effect of douching on vaginal health among HIV-infected women. The prevalence of detectable HIV genital shedding was overall low, 27.3%, compared to that of plasma viral load, 79.8%. While not statistically significant, only 18.9% of non-douchers had genital HIV shedding while 31.9% of women who douched had shedding. Recent intercourse must be noted and a large body of work is focusing on the impact of semen on HIV transmission.